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OBSTETRIC 



GYNECOLOGIC NURSING 



BY 

EDWARD R DAVIS, A.M,, M.D. 

Professor of Obstetrics in the Jefferson Medical College, Philadelphia; 
Obstetrician to the Jefferson Hospital ; Obstetrician and 
Gynecologist to the Philadelphia Hospital ; Con- 
sultant to the Preston Retreat, etc. 



THIRD EDITION, THOROUGHLY REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
J908 



-^^ 



r\ 






LIBRARY of congress] 
I wo CoDies Hece«T«KT 

JUN 24 1908 

CLASS A XXc. (iu. 

COPY a. 



Set up, electrotyped, printed, and copyrighted January, 1901. Reprinted 

November, 1901. Revised, reprinted, and recopyrighted April, 

1904. Reprinted January, 1906. Revised, reprinted, 

and recopyrighted January, 1908. 

Copyright, T908, by W. B. Saunders Company. 



PRINTED IN .) 



PRESS OF 

W. B. SAUNDERS COMPAN' 

PHILADELPHIA 



PREFACE TO THE THIRD EDITION. 



The third edition of this book has been thoroughly 
revised and considerably enlarged. It is offered to 
trained nurses with the hope that it will prove useful 
to them, and as an acknowledgment of the writer's 
appreciation of the important part which trained nursing 
bears in the application of medical science. 

The writer is indebted to Miss Martin and to Miss 
Shaw of the Jefferson Maternity for many suggestions 
of practical value. His acknowledgments are also 
made to Miss M. E. Smith, Superintendent of the 
University Hospital, Miss Margaret Donahoe, Chief 
Nurse of the Philadelphia Hospital, Miss Walker, 
Superintendent of Nurses at the Pennsylvania Hospital, 
and to Mrs. Kammerer, for information concerning 
details of treatment and for the loan of illustrations. 

250 South Twenty-first Street. 
January, 1908. 



CONTENTS. 



PART I.— OBSTETRIC NURSING. 



PAGE 

Introduction ii 

CHAPTER I. 

Definition of Pregnancy; The Growth of the Ovum 13 

The Fetus, 14 — Physiology of Pregnancy, 16 — Anatomy of 
Pregnancy, 19 — Medical Care During Pregnancy, 21 — The 
Breasts, 22. 

CHAPTER II. 

The Nursing of Normal Pregnancy 23 

Diet, 24 — Clothing, 24 — Exercise, 26 — Motoring, 27 — Fresh 
Air, 27 — Quiet, 27 — Baths, 27 — -Growth of. the Uterus, 28 — 
Descent of Child, 28— Uterine Contractions, 29 — Fetal Move- 
ments, 30 — The Breasts, 30 — Morning Sickness, 32 — Constipa- 
tion, 7^T^ — Irritability of the Bladder, 34 — Faintness, 35 — 
Swelling of the Legs, 36. 

CHAPTER III. 

Nursing in the Complications of Pregnancy 37 

Impaction of Feces and Displacements of the Womb, 37 — 
Pernicious Nausea of Pregnancy, 40 — Toxemia and Threatened 
Eclampsia, 47. 

CHAPTER IV. 

Labor, Description of and Preparations for 50 

Pains, 51 — Recognition of Labor, 52 — First Stage, 52 — Sec- 
ond Stage, 53 — Third Stage, 56 — Preparations for Labor, 56 — ■ 
Dressings, 57 — Medicines, 62 — List, 62 — Room for Confine- 
ment, 63 — Bed, 64 — Basins and Clothing, 64 — Ligatures, 64 — 
Baby-clothes, 65 — Crib, 65. 

CHAPTER V. 

The Duties of the Nurse during the Patient's Labor ... 67 
The First Stage, 67 — The Second Stage, 70 — The Third 
Stage, 72 — Lacerations, 72 — Douches, 73 — The Binder, 75 — 
Labor without the Doctor, 75 — Labor with Breech Presentation, 
78 — Twin Labor, 79. 

3 



4 CONTENTS. 

CHAPTER VI. PAGE 

The Puerperal or Lying-in Period 80 

Duration, 80 — Involution, 80 — Lochia and Bowels, 80 — Rest, 
81 — Soiled Linen, 81 — The Newborn Child, 82 — Cleanliness 
for the Mother, 82 — Massage and Posture, 83 — Light and Air, 
84 — Mother and Child, 84 — Warmth, 85 — Bowel Movements, 
85 — Diet, 86 — Asepsis and Drainage, 87 — The Breasts, 89 — 
Catheter, go — Asepsis, 90 — Visitors, 91— Getting Up, 92 — 
Physician's Examination, 93 — The Mother's Figure, 93. 

CHAPTER VII. 

The Newborn Child and Its Care 95 

Physiology of the Infant, 95 — Its First Food, 96 — Mother's 
Milk, 97 — The Child's Stomach, 98 — Nursing, 98 — Water, 99— 
Warmth for the Child, 100 — Sleep, 100 — Clothing, 100 — Bath- 
ing, loi- — Massage, 103 — Dressing the Umbilicus, 103 — The 
Mouth, 104 — The Eyes, 104 — Habits and Nerves, 105 — The 
First Discharges from the Bladder and Bowels, 105. 

CHAPTER VIII. 

The Accidents of Pregnancy 106 

Abortion, 106 — Rest, 107 — Asepsis, 107 — Consequences of 
Abortion, 107 — Bleeding, 108 — Enlarged Veins, 109 — Rupture 
of Membranes, no — Convulsions (Eclampsia), in — Syncope, 
112. 

CHAPTER IX. 

The Accidents of Labor 114 

Hemorrhage During and After Labor, 114 — What the Nurse 
Must Do, 116 — To Prevent Return of Bleeding, 117 — Trans- 
fusion, 118 — Tamponade, 118 — Convalescence, 119 — Prolapse 
of the Umbilical Cord, 119 — Asphyxia of the Child, 120 — Clean- 
sing of the Mouth, 121 — Artificial Breathing, 121 — Stimulation, 
122 — Favorable and Unfavorable Signs, 122. 



CHAPTER X. 
Obstetric Surgery 



In Private Houses, 123 — Sterilizing Utensils, 124 — Clothing, 
125 — Light, 125 — Preparation of Patient, 125 — Anesthesia, 126 
— Anesthesia l\v the Nurse, 127 — Instruments, 129 — Delivery 
by Forceps, 130 — Walcher's Position, 135 — Version or Turning, 
136 — ^Symphysiotomy; Pubiotomy, 137 — Embryotomy (Craniot- 
omy), 139 — Delivery by Abdominal Section (Cesarean Section), 
140 — The Induction of Labor, 148 — The Immediate or Primary 
Repair of Lacerations, 149 — Obstetric Operations in Septic 
Cases, 153 — Plastic Surgery, 157 — Late or Secondary Opera- 
tions for Laceration of the Vagina, Pelvic Floor, and Perineum, 
162. 



1-^3 



CONTENTS. 5 

CHAPTER XI. PAGE 

Nursing in Puerperal Sepsis 169 

Symptoms, i6g — Cleansing the Birth-canal, 170 — Purgatives; 
Counter-irritation, 170 — Treatment of Fever, 171 — Nourish- 
ment, 172 — Stimulation, 172 — Operations, 173 — Bedsores, 173 
— The Nurse, 174 — Nursing the Child, 175. 

CHAPTER XH. 

Complications of the Lying-in Period 176 

Complications with the Breasts, 176 — Excess of Milk, 176 — 
Lack of Milk, 176 — Distention of the Breasts, 177 — Medicines, 
178 — Abnormal Nipples, 179 — Cracks and Fissures in the Nip- 
ples, 180 — Ulcers on the Nipples, 181 — Abnormal Milk, 181 — 
Breast-abscess, 181 — Puerperal Thrombosis of the Lower Ex- 
tremities, 184 — After-pains, 185. 

CHAPTER Xni. 

Puerperal Mania i87 

Treatment, 187 — Precautions, 188. 

CHAPTER XIV. 

Partial or Mixed Feeding; Weaning; Artificial Feeding. . 189 
Advantages of Nursing, 189 — Feeding and Nursing, 189 — ■ 
Prescription of Food for Infants, 189 — Dilution of Cows' Milk, 
190 — Cleanliness with Milk, 190 — Preparation of Milk, 191 — 
Bottles, 191 — Nipples, 192 — Weaning, 192 — Composition and 
Care of Cows' Milk, 193 — ^Mixing and Pasteurizing or Sterilizing 
Milk, 194 — Emergency Feeding, 197 — Gruels, 199 — Beef -juice, 
199 — Medicines and Proprietary Foods, 199 — Feeding without 
the Bottle, 200 — Colic, 200 — Record of Feeding, 200 — Infant's 
Stools, 200 — Indigestion, 201 — The Child's Habits, 201 — Con- 
stipation or Diarrhea, 202. 

CHAPTER XV. 

Care of Prematurely-born Children 203 

Incubation, 203 — Fresh Air, 205 — Dressing the Child, 205 — 
Feeding, 206 — Stimulation and General Care, 206. 

CHAPTER XVI. 

Disorders of Infancy 209 

Constipation, 209 — Disorders of the Mouth and Gums, 211 — 
Diseases of the Lungs in Infants, 213 — Septic Infection in In- 
fants, 216 — Wounds and Injuries of Infants, 216 — Bleeding 
from the Umbilicus; Protruding Umbilicus, 218 — Eruptions in 
Infants, 219. 



6 CONTENTS. 

CHAPTER XVII. PAGE 

Disorders of Infancy {Continued) 221 

Ophthalmia Neonatorum, 221 — Earache, 225 — Foreign Bod- 
ies in the Eye, Nose, and Throat, 226 — Intussusception, 227 — 
Malformations, 228 — Retention of Urine, 228 — Circumcision, 
229 — Dilatation, 230 — Hare-lip and Cleft Palate, 231. 

CHAPTER XVIII. 

Disorders of Infancy {Continued) 233 

Hernia, 233 — Cyanosis, 233 — Tongue-tie, 234 — Constitu- 
tional Disorders, 234 — Rickets, 234 — Tuberculosis, 235 — Hy- 
drocephalus, 235 — Marasmus, 236 — Parasites, 236 — The Itch 
Insect, 237 — Intestinal Parasites, 237 — Jaundice, 238 — En- 
largement of the Breasts, 239 — Suppression of Urine, 239 — 
Persistence of Meconium, 240 — Eczema, 240 — Scalp Crusts, 
241 — Convulsions, 242 — Vaccination, 243. 

CHAPTER XIX. 

The Development of the Child 245 

Weight, 245 — Length, 247 — General Development, 247 — The 
Nervous System, 247 — The Care of the Nerves, 249 — Motion, 
249 — Periods of Development, 251 — Dentition, 252 — To Pro- 
mote Development, 253 — Care during Teething, 254 — Exercise 
and Air, 254. 



PART II.— GYNECOLOGIC NURSING. 



Introduction 256 

Definition, 256 — Causes of Disease, 256 — Peculiarities of 
Patients, 257 — The Management of Patients, 257. 

CHAPTER I. 

The Examination of Patients 259 

Preparation for Examination, 259 — An Office Examination, 
259— Instruments, 260— Antiseptic Solutions, 261 — Cotton or 
Gauze, 261 — Light, 261 — Examination in Private Houses, 261 — 
Description of Instruments for Examination, 263 — Specula, 263 
—Examination under Ether, 265— Duties of Office Nurse, 265. 

CHAPTER 11. 
Postures of the Patient for Examination and Operation. 268 
Dorsal or Lithotomy Position, 268— Sims' Position, 269— 
Knee-chest Position, 271— Trendelenburg Position, 271— Stand- 
ing Position, 274 — Squatting Position, 274 — Position Bending 
Forward, 275. 



CONTENTS. 7 

CHAPTER III. PAGE 

Local Treatment; Pessaries 276 

Local Treatment, 276 — Posture, 277 — Tampon, 277 — Carded- 
wool Tampons, 278 — Vaginal Capsules, 278 — Pessaries, 279 
— Introduction of the Pessary, 280 — Caution to Patients, 280 — 
Removal and Readjustment of the Pessary, 281. 

CHAPTER IV. 

Douches 282 

Vaginal Douches, 282 — The Hot Vaginal Douche, 282 — 
Astringent Vaginal Douches, 283— Antiseptic Vaginal Douches, 
283 — The Temperature and Quantity of Douches, 286 — S}t- 
inges and Douche-tubes, 286 — Posture of Patient, 287 — Douche- 
pans, 287 — Method of Giving Douches, 288 — Cautions and 
Dangers in the Use of Douches, 290 — Douches after Plastic 
Operations, 291 — Intestinal Douches, 292 — Solutions, 292 — 
Tubes for Intestinal Douches, 292 — Posture of the Patient, 
292 — Method of Giving, 292 — Vesical Douches, 293— Fluid 
Employed, 293 — Posture and Preparation of the Patient, 294 — 
Method of Giving the Douche, 295 — Care of the Apparatus 
Employed, 296. 

CHAPTER V. 
General Care of Gynecologic Patients 297 

Rest, 297 — Food, 298 — Forced Feeding in the Insane, 298 — 
Rectal Feeding, 299 — Water, 299 — The Care of the Eyes, 300 
— The Care of the Skin, 300 — Manicuring and Pedicuring, 300 
— Care of the Mouth and Teeth, 301 — General Massage, 301 
— Intestinal Massage, 301 — Intestinal Massage with Salines, 
302 — Pelvic Massage, 302 — Postural Gymnastics, 303 — Elec- 
trical Treatment, 303 — The Care of the Intestines, 304. 

CHAPTER VI. 

Gynecologic Operations 305 

Operations in which the Peritoneal Cavity is Not Opened, 
305 — Preparation of the Patient, 306 — Preparation of Room in 
Private House, 307 — Sterilizer and Instruments, 308 — Needles 
and Sutures, 308 — Solutions and Stimulants, 308 — Operations of 
This Sort in Hospitals, 309— The After-care of These Patients. 
310. 

CHAPTER VII. 
Operations in which the Peritoneal Cavity is Opened ... 311 

Nature's Safeguards, 311 — Preparatory Treatment, 312 — The 
Dangers of Celiotomy, Abdominal or Vaginal, 312 — Preliminary 
Treatment, 313 — Operating-room, 316 — Anesthetizing-room, 
317 — Sterilizing-room, 318 — St^re-room, 318 — Recovery-room, 
318 — Doctor's Dressing-room, 319 — Apparatus, 319 — Prepara- 



8 CONTENTS. 

PAGE 
tion of Operating-room and Furniture, 326 — Improvised Op- 
erating-room in Private House, 326 — Improvised Apparatus, 
^27 — Dressings and Solutions for Cases in Private Houses, 328 
— Emergencies in Private Houses, 328. 

CHAPTER VIII. 

Immediate Preparation for Operation 329 

Sterilization of the Hands of Physicians and Nurses, 329— 
Gloves, 332— Antiseptic Covers for Jars and Tables, 332 — Pre- 
liminary Preparation of the Abdomen and Vagina, 333— Final 
Preparation, 335— The Anesthetizer, 337— Physician's Clothing, 
337 — Dress for Nurses, 338 — DiscipUne of the Operating-room, 
339— Training of Nurses in Operative Work, 340. 

CHAPTER IX. 
After the Operation 341 

Arrangement of the Patient's Room, 341 — Vomiting, 342 — 
Hemorrhage and Shock, 343 — Septic Infection, 346 — Restless- 
ness and Thirst, 350 — Abdominal Distention, 351 — Food and 
Stimulants, 352 — The First Movement of the Bowels, 353 — The 
Use of the Catheter, 354 — Increased Diet, 355 — Stimulation by 
the Mouth, 355 — Changes of Posture, 356 — The Care of the 
Skin, 356 — The Care of the Drainage-tube, 357 — When is a 
Patient Convalescent after Abdominal Section? 358 — The 
Nurse, 359. 

CHAPTER X. 

Convalescence and Recovery 361 

Re-dressing, 362 — The Removal of the Stitches, 363 — Stitch- 
hole Abscess, 364 — Changes in Diet, 365 — Sitting Up, 365 — 
Ventral^ Hernia, 366 — Sudden Death during Recovery from 
Abdominal Operation, 367. 

CHAPTER XI. 

\'aginal Celiotomy 369 

Preparations for Vaginal Celiotomy, 369— Posture, 369 — In- 
struments and Appliances, 370 — Hemorrhage and Shock, 370 — 
After-treatment, 370 — Dressings, 370 — Convalescence, 371. 

CHAPTER XII. 

Cancer ^72 

Suspicious Symptoms, 372^Cancer of the Pelvic Organs, 372 
. — Cancer of the Breast, 374 — Non-operative Treatment of 
Cancer, 376 — Cancer of the Bladder or Bowel, 377 — Bed-sores, 
379— Pain, 379— Death from Cancer, 380— Dangers of Infec- 
tion, 380 — Dangers to the Nurse, 381. 



CONTENTS. 9 

CHAPTER XIII. PAGE 

Mental Diseases Complicating Pelvic Disorders 382 

Melancholia, 382 — Perversions, 382 — Mania, 383 — General 
Care, 383 — The Menopause, 384. 

CHAPTER XIV. 

Venereal or Specific Disease 386 

Gonorrhea, 386 — The Effects of Gonorrhea, 386— The Con- 
veyance of Gonorrhea, 387 — Treatment, 387 — Care of the 
Nurse, 388 — Syphilis, 388 — Treatment, 388 — The Results of 
Syphilis, 389 — The Treatment of Hereditary Syphihs, 389 — 
Precautions for Nurses in Dealing with These Cases, 390. 



APPENDIX. 

Dietary 391 

Preparation of Surgical Supplies 396 

Other Methods for the Preparation of Surgical Supplies 
and Aseptic Precautions 412 



PART I. 

Obstetric Nursing. 



INTRODUCTION. 



Obstetric nursing is that branch of the art of caring 
for the sick which includes the nursing of the mother 
during pregnancy, parturition, and the puerperal state, 
and also the care of her child. 

It demands some knowledge of natural pregnancy and 
of the signs of accidents and diseases which may occur 
during pregnancy. It also requires knowledge and ex- 
perience in the care of the patient during the labor and 
during her complete recovery, with the needs of her child. 
The obstetric nurse must also know how to help patient 
and doctor in the accidents and complications of labor, 
and has an important part to play in caring for mother 
and child in the diseases which occasionally attack them 
during the puerperal period. As wounds occur during 
labor, and as operations must often be performed during 
or immediately after labor, a thorough knowledge and 
drill in asepsis and antisepsis are absolutely indispensable. 

The field of obstetric nursing is thus a wide one. 
Some of the most remarkable physiologic changes 
known in the human body accompany pregnancy and 
parturition ; while few patients are so absolutely healthy 



1 2 INTR OD UCTION. 

that pregnancy and childbirth proceed in a perfectly 
natural way. 

The personal relations of the obstetric nurse with her 
patients are peculiarly interesting. The coming of the 
child is usually an occasion of joyful anticipation, while 
the accidents and diseases occurring at this time may 
become very rapidly serious and be followed by a tragic 
termination. No nurse who gives good and faithful ser- 
vice is more thoroughly appreciated by her patients and 
the physician in charge. The affection given so freely to 
the child is often extended to the nurse, and firm and 
lasting attachments of a most interesting nature often 
develop. 

To nurses gifted with good health and strength, who 
have opportunities for proper training and experience, 
and who are naturally fond of young children, obstetric 
nursing offers an exceedingly interesting and very lucra- 
tive branch of medical work. 



CHAPTER I. 

DEFINITION OF PREGNANCY.— THE GROWTH OF 
THE OVUM.— THE FETUS.— THE ANATOMIC 
STUDY OF PREGNANCY. 

Pregnancy. — By the term " pregnancy " is under- 
stood the presence of the impregnated ovum within the 
body of the mother. The ova are formed in the ovaries, 
from which they are discharged by the bursting of the 
sacs in which they are contained, and from which they 
pass through the oviducts, or Fallopian tubes, into the 
uterus, or womb. Impregnation may occur in the Fal- 
lopian tubes, and very rarely in the burst sac of the 
ovary. When the impregnated ovum has lodged in the 
womb and develops there to maturity, the pregnancy is 
said to be normal, intra-uterine, or entopic. When the 
impregnated ovum remains in the Fallopian tube or 
escapes thence into the abdomen or into the pelvis, the 
pregnancy is said to be abnormal, extra-uterine, or 
ectopic. 

Growth of the Embryo. — When the impregnated 
ovum reaches the womb, it usually lodges in the upper por- 
tion of the uterus near the openings of the Fallopian tubes. 
It fastens itself to the lining membrane of the womb, and 
gradually forms membranes of its own which surround 
it. For the first few months of its development it is 
called an embryo. It resembles a small bladder, or cyst, 
covered on its outer surface with white shaggy projec- 

13 



14 PREGNANCY. 

tions which look like fringes of moss or like a soft and 
white chestnut burr (Fig. i). These projections are upon 
the outer membrane covering the embryo, called the 
chorion, and are the tendrils by means of which the 
embryo clings to the wall of the womb. Within the 
chorion and next the embryo is a very thin and delicate 
membrane, called the amnion, which forms a fluid, called 
the amniotic fluid, in which the growing embryo moves 
during its development. 

The characteristic form of the human being is seen in 
very early embryos. The limbs are soon developed ; the 





Fig. I. — Human ovum of about twelve days (Reichert) : A, side view; B, front view. 

eyes appear in primitive form ; the body is bent slightly 
forward, while the embryo moves in the amniotic liquid. 
It obtains its nourishment through a vesicle, or bladder, 
which contains rudimentary blood-vessels which after- 
ward enter into the umbilical cord. During the first 
three months of pregnancy this description of the em- 
bryo would apply, and the chorion can usually be recog- 
nized by its pale and shaggy appearance, in cases in 
which the embryo is expelled, when the specimen is 
floated on cold water in a white vessel. 

The Fetus. — At about the fourth month of gesta- 



THE FETUS. I 5 

tion the after-birth, or placenta, begins to be formed, 
while the membranes rapidly grow larger to give greater 
space for the growing embryo. The name " fetus " is 
now applied to the young being, and the umbilical cord 
gradually develops, connecting the placenta to the 
umbilicus of the fetus. The form of the fetus is distinct 
and characteristic of the human being, the fingers and 
toes gradually become separated from each other, the 
eyes develop completely, and gradually the usual appear- 
ances of a newborn child are present in varying degree. 

At tw^enty-six weeks of gestation the fetus has grown 
so large that it is possible for it to live outside the body 
of the mother. It is exceedingly unlikely, however, that 
such would be the case with most infants. At tw^enty- 
eight weeks, or seven months, children have often sur- 
vived, and from this time on to the usual termination of 
pregnancy children are frequently born and live. 

Position and Presentation. — During this time the 
child has assumed its position in the mother's womb, 
which in most cases is with the head low^ermost, the 
back of the child turned toward the mother's left side, 
and the feet and knees upon her right side, just above 
the middle of the womb. The placenta growls in pro- 
portion to the weight and vigor of the child. The cord 
is sufficiently long to permit free movement on the part 
of the child, while the amniotic liquid provides a use- 
ful protective against injury and also a suitable medium 
in which fetal movements can occur. In some cases the 
head of the fetus is lowest and the back is turned to 
the mother's right side. In other cases the breech and 
thighs of the child are lowest, while the head is upper- 
most in the womb. Occasionally the child lies trans- 
versely in the uterus, with its head upon one side and its 
feet and limbs upon the other. 



1 6 PREGNANCY. 

Full-term Pregnancy. — Pregnancy usually lasts in 
normal cases two hundred and eighty days. It cannot 
be said to be abnormal if it continues three hundred 
days, nor if it terminates at two hundred and seventy 
days. The average child at full term is twenty inches 
(fifty centimeters) long, weighs from six and one-half to 
seven and one-half pounds, is strong enough to cry 
vigorously and to suck the nipple of the mother, and is 
fully capable of living outside the mother's womb. Its 
placenta, or after-birth, weighs about a pound, and the 
umbilical cord is usually from fifteen to twenty-five inches 
in length. While the bones of the child are fairly de- 
veloped, those of the skull are not tightly knit together, 
but can be moved at the edges, and in some instances 
can be made slightly to overlap. There are several 
membranous spaces along the central line of the fetal 
skull, the largest of which is called the anterior fontanel. 
This name was given because the beating of the blood in 
the brain can be seen at this point in the rise and fall of 
the membranes covering the brain. As this movement 
resembles that of a fountain, the space has been called a 
fontanel. 

The Physiology of Pregnancy.— During preg- 
nancy the healthy mother grows in all portions of the 
body. To feed herself and the child, the blood becomes 
abnormally rich, the muscle of the heart is larger and 
stronger than usual, the various organs of nutrition are 
increased in size and activity, and the skeleton becomes 
larger and heavier. The increase in blood is often evi- 
dent in the darker color of the lips and other mucous 
membranes. In many patients the appetite is increased, 
the patient feels stronger and better than before, and is 
capable of considerable exertion. In healthy women the 



PLATE I. 




Ci^ ^:!^Obb p ^ 



i - ^^ 5 i 




THE PHYSIOLOGY OF PREGNANCY. 1/ 

excretions are increased and an additional quantity of 
oxygen is required to purify the blood. A vaginal dis- 
charge of whitish mucus is commonly observed during 
pregnancy and is a natural thing. The normal vaginal 
discharge in a healthy pregnant patient is capable of 
destroying bacteria, and is thus of value in protecting 
the mother. It should not be removed by douches in 
healthful cases, hence a nurse should not give a vaginal 
douche to a pregnant patient, not even if labor is begin- 
ning, without the distinct order of the physician in 
charge. 

As pregnancy progresses, the size of the womb varies 
at different periods. 

At four months the womb can be distinctly felt in the 
abdomen above the pubes, at five months it is midway 
between the pubes and the umbilicus, at six months the 
top of the womb is at the umbilicus, at seven months 
it is two fingers' breadth above, at eight months it is 
a hand's breadth above the umbilicus, and at nine months 
it is distending the tissues at the tip of the breast-bone 
or sternum (Plate 2). 

After the ninth month, in patients who are pregnant 
for the first time, the child usually descends into the 
pelvic brim, and the uterus is lower down. In patients 
who have had several pregnancies the child remains 
above the pelvis until labor begins. 

The child in the womb is usually situated with the 
head lowest at the brim of the mother's pelvis (Fig. 2). 
In most cases the back of the child is on the left side of 
the mother, and the heart-sounds of the child are heard 
on the mother's left side between the crest of the pelvis 
and the umbilicus. Occasionally the child has the head 
uppermost and the breech lowest in the womb, and, very 



i8 



PREGNANCY. 




rarely, the child is turned transversely in the uterus. 
Occasionally the face instead of the vertex of the head is 
situated at the upper part of the 
pelvis. That part of the child 
which is lowest in the womb is 
said to present, and various situa- 
tions of the child's body, with 
reference to the mother, are said 
to be its positions. 

When more than one child is 
in the womb at the same time 
they fit into the uterus as best 
they can, usually the head of one 
being lowest and the head of the 
other being above. 

The after-birth is usually at- 
tached to the posterior wall of the 
womb some distance above the 
opening at the mouth. 
The child while within the uterus has lived through 
oxygen obtained from the mother's blood. The blood 
of the child passing through the umbilical cord into 
the placenta comes there so close to the blood of the 
mother that oxygen passes from the maternal into the 
fetal blood. Thus the child has had no need to breathe. 
Its lungs have required but very little blood. For this 
reason the circulation of blood in the unborn child differs 
from that in the child after birth. Before birth there is an 
opening in the partition between the two sides of the 
child's heart, and, as blood is not needed in large quantity 
in the lungs, it passes from the right side of the fetal heart 
into the left side, instead of going from the right side of 
the heart into the lungs. So soon as the child is born 
and the umbilical cord has been tied and cut, it ceases to 



Fig. 2. — Adaptation between 
the uterus and the fetus at term 
in vertex presentation (Ameri- 
can Text-Book of Obstetrics). 



THE ANATOMY OF PREGNANCY. 1 9 

obtain oxygen from its mother. It begins to breathe. 
Its lungs unfold and admit air and the opening between 
the two sides of the heart closes. To help this the child 
should be laid upon the right side for the first day or so 
after birth. Several days are required to unfold fully 
the lungs and to seal perfectly the opening in the heart. 
If this does not completely shut, the blood of the child 
remains without its proper quantity of oxygen, the child 
is blue in the face, and is often called a " blue baby." 

Not only does the child within the womb obtain oxygen 
from the blood of the mother, but some nutritious matter 
passes into the fetal blood, while the fetus discharges into 
the blood of the mother some of the waste matter from 
its own body. As the fetus during its development 
lives entirely upon the mother, it is evident that she 
requires abundant food of an easily digestible character ; 
that she should have the greatest possible supply of fresh, 
pure air ; and that she should discharge freely the waste 
from her own body through the kidneys, intestines, skin, 
lungs, and liver, because she is burdened with her own 
waste and that of the fetus as well. 

The Anatomy of Pregnancy. — The womb, or ute- 
rus, in which the child is developed is a hollow muscu- 
lar organ which increases in size with the growth of the 
child. Its muscular tissue is so interwoven that when it 
contracts it exerts great expulsive force. Although the 
womb before pregnancy is only two and a half to three 
inches in length, it becomes many times larger, ex- 
tending with the child almost the entire length of the 
abdomen nearly to the diaphragm. As the womb grows 
it draws up somewhat the ovary and the Fallopian tube 
upon each side. As pregnancy proceeds the womb lies 
a little obliquely across the abdomen, its upper portion 
being a little to the right of the median line, and its lower 



20 PREGNANCY. 

portion inclined a little to the left. It pushes the intes- 
tines to each side, often compressing them to such an 
extent that constipation results. 

The Fallopian tubes are composed of muscular tissue, 
elastic tissue, and mucous membrane, resembling the 
uterus in structure. They are capable of slight con- 
tractions, and, should the impregnated ovum remain in 
the tube, it can develop to a certain point. The ovaries 
during pregnancy are usually quiescent, and menstrua- 
tion does not, as a rule, continue during pregnancy. 

The Birth-caiial. — The Fallopian tubes, the uterus, 
the vagina, and the muscular floor of the pelvis com- 
prise what is known as the birth-canal. This is con- 
tained in the pelvis, or bony basin. When the child has 
fully developed, labor must come on to secure the ex- 
pulsion of the fetus from the mother's womb. The child 
is pressed out from the body of the mother by the con- 
traction of the uterine muscle aided by the diaphragm 
and the abdominal muscles. The lower part of the 
womb, called the neck, or cervix, dilates or stretches, 
while the vagina and pelvic floor dilate and relax to 
allow the passage of the child. If the child be large, 
and if the tissues do not dilate readily, then lacerations, 
or tears, may result. If such tears be not closed by 
sutures, some portion of the birth-canal will sag down- 
ward or prolapse, and the supports of the womb being 
weakened, the uterus may assume abnormal positions, 
and the patient suffer as a consequence. The muscular 
and elastic tissues described form a continuous canal or 
muscular tube. 

The Bofiy Pelvis. — The bony pelvis of the mother 
comprises the sacrum, which forms the posterior wall of 
the pelvis, and two large, irregularly shaped bones one 
upon each side, called the innominate bones. The two 



THE ANATOMY OF PREGNANCY. 21 

side bones of the pelvis have different names in their 
different portions. Thus in front the two halves are 
termed the pubic bones, while at the lowest point near 
the rectum we have the ischia. The thigh-bones, or 
femora, fit into sockets at each side of the pelvis. 
These bones are bound together by ligaments, and 
the whole forms an irregularly shaped bony cavity 
which may undergo some change in form and contour 
during pregnancy and labor. The shape of the normal 
pelvis is caused by the healthy development of the 
mother, not only through inherited good health, but 
also through exercise. When, however, the mother has 
a disease of the skeleton like rickets, or when during 
early life she is prevented from walking and from exer- 
cising as she naturally would, deformity of the pelvis 
results. - Bony tumors occasionally grow upon the walls 
of the pelvis and obstruct its cavity. 

When in any way the pelvis becomes deformed, it is 
evident that its space may be so lessened that a healthy, 
full-term child cannot pass through. The mother cannot 
in such a case deliver herself, and the life of her child 
and often her own life must be rescued by an obstetric 
operation. 

Medical Care during Pregnancy. — From what 
has been said regarding the growth of the child and 
the development of the pelvis, either natural or un- 
natural, it follows that each pregnant woman should 
early consult a physician. If anything unnatural be 
present, the physician can usually detect it during the 
pregnancy. Each patient should be seen as early as the 
third month of gestation. The physician will thoroughly 
examine the patient, and will detect complications which 
if neglected may jeopardizethe lives of mother and 
child when the mother comes into labor. By palpation 



22 PREGNANCY. 

and auscultation at the seventh month the physician 
can discover the period of pregnancy, the attitude and 
location of the fetus, and oftentimes of the placenta as 
well. By measuring the pelvis he will know whether 
it is normal or not; and if it be misshapen or too 
small, he may cause the pregnancy to end soon enough 
to obtain a living child before it becomes too large to 
pass readily through the pelvis. He can usually detect 
an unnatural position of the placenta ; and, as some of 
these are very dangerous, he may interfere in time to 
save the lives of mother and child. 

The Breasts. — During pregnancy the breasts, or 
mammary glands, develop to provide nourishment for the 
child. They become larger, firmer, oftentimes sensitive 
to pressure, while coloring-matter is deposited around the 
nipples, making this portion of the breasts very much 
darker. If the nipples are not deformed, they grow and 
project as pregnancy advances. In many cases, however, 
they are congenitally deformed, are badly developed, or 
have been stunted in their growth by the pressure of cor- 
sets or tight clothing. In some cases cracks or fissures in 
the mucous membrane covering the nipple develop ; and 
unless careful attention be given to this condition serious 
trouble for mother and child may result. If these cases 
be detected in time, under appropriate treatment they 
are cured, and the patient escapes a complication trying 
for both mother and child. 

From this sketch of the growth of the embryo and of 
the birth-canal during pregnancy we may appreciate how 
great are the changes which pregnancy causes in the 
body of the mother, and how necessary it is that she 
receive proper care during this time, that her own health 
and that of the child be successfully continued during 
this period. 



CHAPTER II. 
THE NURSING OF NORMAL PREGNANCY. 

It Is true that women who remain in fairly good health 
during pregnancy seldom have the services of a nurse. 
There are, however, many things regarding which the 
pregnant woman often asks advice, and some respects in 
which she profits by special care and attention. 

When the fact of pregnancy has become known to 
the mother, she naturally desires so to live as to secure 
not only her own health, but also the health and de- 
velopment of her child. There are many instances 
which show how profoundly the mother's condition dur- 
ing pregnancy affects fetal development. Women who 
are partially starved, or who habitually take poisonous 
drugs Hke alcohol, are badly nourished themselves, and 
bring forth children deficient in strength and develop- 
ment. Famine, war, and pestilence show their effects 
upon children born during these periods. Prolonged 
sorrow and great mental depression during pregnancy 
seriously affect the child. On the other hand, an abun- 
dance of properly selected food, an abundance of fresh air, 
gentle exercise, and, above all, a tranquil and happy 
ner\^ous state, with freedom from shock and disturbance, 
tend to produce the best development of the child. To 
obtain this mode of life is very difficult, and the mother 
who does so must give up some of the occupations and 
pleasures which she would otherw^ise enjoy. She must, 



24 THE NURSING OF NORMAL PREGNANCY. 

for example, avoid crowded rooms, overheated buildings, 
excitement, indigestible food, late hours, and fatigue, such 
as women often experience in prolonged shopping or at 
social functions. Many women are glad to do this in 
view of what they hope to accomplish by it, while others 
are too selfish to change their mode of life. 

Those who struggle with care and poverty cannot 
obtain the best mode of life, and they and their offspring 
suffer as a consequence. Their overtaxed condition pro- 
duces a frail and nervous state in the child. 

Diet. — The diet of normal pregnancy should be based 
primarily upon three kinds of simple food, namely, milk, 
fruit, and bread. The quantity of meat taken should be 
distinctly curtailed, and meat should not be used more 
often than once daily. Fish or eggs in season may be 
taken in place of meat. All fruits and vegetables in 
season may be used, fruits being especially valuable 
because of their laxative properties and of their stimu- 
lating action upon digestion. Rich foods, fried dishes, 
pastry, large quantities of meat, sweets, indigestible 
salads, nuts, pickles, cheese, candies, lobster and crabs, 
large quantities of tea and coffee, or alcohol should 
be distinctly avoided. It is in the rarest cases only that 
the pregnant woman requires alcohol. Some patients 
do not enjoy milk unless it- is diluted with effervescing 
waters, or unless it is prepared by rennet or is made 
into milk puddings, custards, koumiss, or is taken with 
gruels. Each pregnant patient needs from one to two 
quarts of water in twenty-four hours. The greater part 
of this should be taken between meals, especially upon 
retiring and on rising in the morning. 

Clothing". — So soon as the first weeks of pregnancy 
are past the patient will naturally desire to be freed from 



DIE T— CL O THING. 



25 



any pressure by her clothing upon the abdomen. This 
can be accompHshed by the use of a suitable waist, to 
which much of the underclothing can be buttoned at its 
lower border, and which obtains its support from the 




Fig. 3. — The ''Equipoise Waist." 



shoulders of the patient. Such a waist can be purchased 
at the shops or may be made to order if desired. The 
Equipoise waist, so called, is a good one of this kind 
(Figs. 3-5). In cold or cool weather thin woollen should 
be worn next the skin over the entire body. Circular 
garters should be replaced by long side garters. Shoes 
and slippers should fit easily, and wraps and all clothing 
should be loose and made with the greatest regard to 
comfort. 



26 



THE NURSING OF NORMAL PREGNANCY. 



Exercise. — If a pregnant patient be suitably dressed 
she will be able to exercise, especially as her pregnancy 
proceeds. Walking at a comfortable pace over a smooth 
path is usually the most enjoyable exercise, although 
driving in an easy carriage over a smooth vo^H i"c also 




Fig. 4. — Patient wearing bandage supporting 
abdomen and breasts during pregnancy. 




;. — Equipoise 
during pregnancy. 



pleasurable. During the first few months of pregnancy 
railway travel should be avoided if possible. After this, 
a railway journey in a comfortable car may often be un- 
dertaken without discomfort. Some patients are much 
nauseated by the motion of a train. 

To be avoided are reaching high above the head, go- 
ing up and down long flights of steep stairs, taking a 
very high step, lifting or straining, riding, bicycHng, and 
using a sewing-machine driven by the feet. 



BATHS AND BATHING. 2/ 

Motoring. — If a motor car is used, a smoothly run- 
ning' machine should be chosen. In most large cars the 
.patient will feel least jarring on the front seat. If possible, 
the car should not run at high speed, and the patient 
should be suitably dressed to avoid chill. Motoring at a 
rapid rate is excessively fatiguing, and pregnant patients 
should take especial care to avoid exhaustion from this 
source. A patient may become easily chilled in rapid 
riding, and this should be avoided. 

Fresh Air. — It is very interesting to note in some 
patients their desire for an abundant supply of fresh 
air. Many are so urgent for it as to make the rooms 
in which they are uncomfortable for other persons. 
This desire is most natural, and should always receive 
attention. All rooms occupied by pregnant patients 
should be most thoroughly aired. This is especially true 
of sleeping-rooms. The best ventilator is an open fire- 
place, and a window containing a board which raises the 
sash from the bottom, leaving an air-space at the junction 
of the upper and lower sash, furnishes excellent ventila- 
tion. 

Quiet. — The need of quiet for pregnant patients is 
very great. The cares and worry of daily life often be- 
come almost unbearable to persons in this condition. It 
must be true that constant disturbance and worry have 
their influence upon the unborn child ; hence if it can 
possibly be obtained, the patient should have the com- 
fort of undisturbed repose. 

Baths and Bathing. — It is especially important that 
the skin of the mother acts freely during this period. 
She should bathe as often as she finds it comfortable to 
do so. The warm tub-bath at night and a moderately 
cool sponge-bath in the morning are the best combina- 



28 THE NURSING OF NORMAL PREGNANCY. 

tion for this condition. The warm bath is an excellent 
means of securing repose and aids sleep, while the cool 
sponge-bath is invigorating and prevents the patient 
from taking cold. Neither hot nor very cold baths 
should be taken. 

Growth of the Uterus. — As pregnancy continues 
certain phenomena are observed which will attract the 
attention of the patient, and will often lead her to question 
a nurse regarding the subject. The abdomen increases 
steadily in size in normal pregnancy, and at four months a 
tumor can be appreciated just above the pubic bone. If 
the patient's abdominal wall is very thick, it may be very 
difficult to find this tumor without deep pressure ; but if 
she be a thin person, the tumor will be found with com- 
parative ease. At this time the uterus begins to rise out 
of the pelvis, and many pressure-symptoms, such as 
irritability of the bowel and bladder, and nausea, are often 
considerably relieved. When six months have elapsed 
the top of the womb is as high as the umbiHcus. When 
seven months, it is two fingers' breadth above the umbili- 
cus, and at eight months a hand's breadth. When nine 
full months have been completed in the first pregnancy 
the womb has risen so far that it puts the tissues attached 
to the tip of the breast-bone, or sternum, on the stretch. 
The patient may often be very uncomfortable from the 
sensation of weight and interference with breathing, while 
the size of the abdomen is very evidently greatly in- 
creased. 

Descent of the Child. — From the end of nine 
months until the time of labor the child gradually 
descends into the mother's pelvis. If it be the first 
pregnancy, the child descends lower than it will in subse- 
quent pregnancies, because the uterus of the mother, being 



Plate 2. 





UTERINE CONTRACTIONS. 29 

strong and elastic, forces the child lower down than in 
other cases. In the first pregnancy the mother feels a 
distinct sense of relief from abdominal pressure, and 
notices that the abdomen grows considerably smaller. 
Her clothing becomes looser at the waist ; she can move 
about with more comfort and breathe with more freedom. 
This is not a sign that the fetus is not doing well, but 
simply that pregnancy is drawing near to its close. There 
may be increased discomfort from the pressure of the 
child's head on the neck of the bladder, and sometimes 
upon the bowel also, but the difference in the abdomen is 
marked. 

In women who have had several children the child does 
not descend so low at this time. The head of the child 
lodges against the side of the pelvis, the womb is not 
so strong and elastic, and hence the patient's size is 
less changed. In women who have borne a considerable 
number of children the womb is often relaxed and some- 
what flabby, and may be broad and hemispheric in shape. 
Symptoms of pressure upon the bladder and rectum are 
not so frequent in women who have borne a number of 
children as in those pregnant for the first time. 

Uterine Contractions. — The uterus contracts and 
relaxes during the entire period of pregnancy. This 
causes the sensation of pain, and the patient may often 
complain bitterly and imagine that labor has begun. 
These contractions and relaxations are very important in 
fitting the child into the mother's pelvis. They naturally 
become more pronounced as pregnancy draws near its 
close, until they finally terminate in the actual beginning 
of labor. If the mother be reclining and the hand be 
laid upon the surface of the uterus, the womb can often 
be felt to contract and then to relax. The meaning of 



30 THE NURSING OF NORMAL PREGNANCY. 

these pains should be known to a mother if they are 
severe ; and if it is not time for the birth of the child she 
should lie down, taking a short period of perfect rest, 
when the pains will usually subside. 

Fetal Movements.— The movements of the fetus 
within the womb are always a source of interest and 
sometimes of alarm to the mother. They are usually 
felt about the fourth month. The sensation is described 
as that of the fluttering of a bird held within a closed 
hand. In young patients pregnant for the first time the 
first movements of the fetus are sometimes very terrifying. 
When their meaning is understood, they occasion no dis- 
quietude. It is very seldom that a precise date can be 
fixed for detecting fetal movements in the first pregnancy. 
They are so faint and slight that considerable experience 
is required actually to detect them. When women have 
had several children they can often state with positiveness 
that fetal movements were present at or very near a cer- 
tain date. Many women are accustomed to use this date 
in computing the probable time of confinement, reckon- 
ing it to be at the fourth month of pregnancy. If the 
fetus moves actively, it excites contraction of the uterine 
muscle, and hence brings about intermittent pains. In 
some cases movements are so active as to interfere 
seriously with the mother's sleep, and in other cases the 
movements give rise to such vigorous contractions of the 
womb that the patient suffers considerably. There is no 
way of controlling the movements of the fetus except by 
having the mother avoid active, violent exercise. This 
will usually bring about a period of considerable repose. 

The Breasts. — Pregnancy is almost invariably char- 
acterized by abnormal sensations in the breasts, which in 
some patients are felt very early. They are described as 



THE BREASTS. 



31 



tingling, pricking, or shooting pains, with great sensitive- 
ness, and sometimes with itching or abnormal sensations 
about the nipple. The breasts are usually sensitive from 
the pressure of clothing, and the patient reaHzes that the 
breasts are increasing rapidly in size. In ordinaiy cases 
little is required in the care of the breasts, if the nipples 
be sound and healthy. They should be examined early 
in pregnancy to ascertain whether the nipples can be 
drawn out by the thumb and finger or by the child in 
nursing, so that they can 
readily be grasped. The 
nipples should always be 
examined for cracks and 
fissures, and especially 
for evidences of sore- 
ness or sensitiveness or 
wounding. Dried secre- 
tions in small crusts are 
often found upon the 
nipples, and should be 
removed by the applica- 
tion of oil, followed by 
gentle washing with Cas- 
tile soap and warm water. 
The breasts are com- 
posed of a number of 
divisions, each containing 
secreting cells, emptying 
into the nipple by small 
tubes or ducts. The dif- 
ferent portions of a breast resemble bunches of grapes ; 
and if several bunches be taken and held together by 
their stems, a simple but fairly accurate representation 




Fig. 6. — Mammary gland : i, milk-ducts; 
2, glandular portion (Plaj-fair). 



32 THE NURSING OF NORMAL PREGNANCY. 

of the breast may be obtained. The stems would rep- 
resent the tubes, or ducts, which empty at the nipple, 
and the branches would represent the different divisions 
of the breasts. The individual grapes upon the bunches 
would represent small collections of secreting cells (Fig. 
6). The nipple is covered with an epitheHal membrane, 
composed of small cells laid upon a supporting mem- 
brane, as a pavement is laid upon the bed of a street. If 
these epithelial cells be in good condition, the nipple will 
be healthy and will not crack nor fissure. If, however, 
these cells be not in good condition, or if they be defi- 
cient in development, when the child nurses the act of 
sucking may strip off the protecting cells and leave a 
raw surface upon the nipple, through which infection 
may enter the lymph-channels or the blood. Hence it 
is very important that during pregnancy the epithelial 
cells of the nipple should be sound and healthy, and 
should be formed in abundant quantities. 

To bring about this result the nipple should first be 
cleansed in a very gentle but thorough manner, to re- 
move dried secretions and any foreign matter which may 
have stuck to the nipple from the patient's clothing. 
Then a mild and simple ointment should be employed, 
which will keep the nipple soft and further the growth 
of cells, and thus put it in healthy condition for the 
child's nursing. 

Morning-sickness. — Among the early phenomena 
of pregnancy many patients experience what is called 
morning-sickness, or the nausea of pregnancy. This is 
usually experienced so soon as the patient wakes, or in 
some cases so soon as she rises from bed. If the 
stomach be promptly emptied, this often ends the nausea; 
and if the patient takes a little liquid food, or a cup of tea 



CONST/PA TION. 3 3 

or coffee, or even of hot water, she goes through the re- 
mainder of the day in comfort. Other patients are nau- 
seated for a longer part of the day, and in some cases the 
condition becomes a very serious one. All pregnant 
patients do not have morning-sickness, but many do; 
and it is so common among patients who employ nurses 
that nurses are very likely to hear of it, and should 
understand its significance. 

Constipation. — As the womb increases in size before 
it rises out of the pelvis into the abdomen, it may cause 
pressure upon the bowel and interfere with their move- 
ment. This is especially true if the womb be tipped 
backward, when it lies almost against the bowel. As 
the uterus grows in size constipation increases, and 
many experience very great difficulty in securing move- 
ments of the bowels during pregnancy. In ordinary 
cases the patient's bowels can be kept in fairly good 
condition by properly selected diet. This should com- 
prise grains so prepared as to leave a portion of the 
husk or coarser part of the grain, which will act as a 
stimulus to the intestine. Oatmeal, cracked wheat, fine 
hominy, breakfast-foods of various kinds, and in some 
cases rice, are all useful for this purpose. Graham-flour 
in the shape of bread or biscuit, and rye flour usually 
mixed with Graham-flour or with white flour, are also 
useful. A liberal supply of fruit, of which the best are 
apples and oranges, should be afforded. The patient's 
appetite often craves large quantities of fruit, and this 
appetite should be indulged to the fullest extent if diges- 
tion remains good. We have known a patient to con- 
sume what seemed to be very large quantities of oranges 
and apples during pregnancy, remaining in excellent 
health. Grapes, rejecting the seeds and skin, are espe- 

3 



34 THE NURSING OF NORMAL PREGNANCY. 

cially useful. Strawberries do not agree with all pregnant 
patients, and some cannot take bananas. With some, un- 
cooked fruit does not agree, although they do perfectly 
well when fruit is stewed or baked. Many prefer apples 
in the form of puddings, and those who cannot use raw 
fruits may substitute dried peaches or fruits put up in 
glass. Most canned or preserved fruits, however, con- 
tain too much sugar to make them suitable articles for 
diet in pregnancy. In avoiding the constipation of preg- 
nancy a liberal quantity of water must be employed, and 
this should be taken not only at meal-times, but also on 
rising and before retiring, and between meals. Any sort 
of water which the patient prefers may be freely used. 
Aerated waters are often very acceptable, especially to 
patients who are suffering from abnormal secretion in the 
stomach or mouth. Apollinaris, Vichy, and soda water, 
are those most often taken. The free use of fruits, 
vegetables, or suitably prepared grains, and the taking 
of plenty of water, with exercise and bathing, will 
prevent serious constipation during pregnancy in the 
majority of cases. It is far better to be careful in this 
regard than constantly to employ drugs in the treatment 
of this condition. 

Very rarely, pregnant patients are affected with diar- 
rhea, which usually results from irritation of the bowel 
produced by pressure of the growing uterus. It sel- 
dom becomes severe, and is usually readily controlled 
by simple changes in the diet. The use of milk or 
of liquids for a few days is usually all that is neces- 
sary. 

Irritability of the Bladder. — Disturbances in the 
functions of the bladder are often caused in pregnancy 
by the pressure of the growing uterus. This is most 



FAINTNESS. 35 

likely to occur at two periods : First, when the uterus 
is not entirely out of the pelvic cavity, and when it is 
directed forward and downward against the neck of the 
bladder or tipped backward ; and second, at the latter 
portion of pregnancy, when the head of the child is 
entering the pelvic brim. The frequent desire for mictu- 
rition and the voiding of small quantities of urine are 
the result of this condition. In the early stages of preg- 
nancy it is often relieved by having the patient assume 
the knee-chest posture (Fig. 7) for a short time night and 




111 mil 

Fig. 7. — The knee-chest position. 

morning. When it occurs just before labor it can only 
be relieved by the removal of the fetus from the uterus. 
The use of a catheter will give temporary benefit, but 
will not result in permanent cure. 

Faintness. — Pregnant patients are often greatly 
annoyed by sensations of fainting, or syncope. In some 
cases this results from weakness, while in others it is 
entirely a nervous phenomenon, and is especially liable 
to result from an overheated room, or some temporary 
excitement or a slight fright. Tregnant patients should 



36 THE NURSING OF NORMAL PREGNANCY. 

avoid close rooms and excitement. When faintness 
occurs the patient should lie down, have the clothing 
loosened, and remain perfectly quiet for a short time. 
The attack will speedily pass, and usually occasions no 
serious complication. 

Swelling of the I^egs. — Swelling of the legs and 
feet is very common during the latter months of preg- 
nancy. If it is worst at evening, if the patient has little 
or no headache, if she does not feel dull or depressed, or 
profoundly melancholic, it is not a serious symptom. If, 
however, it is attended with very scanty secretion of 
urine, with violent headache, throbbing in the temples, 
impaired vision, and great disturbance of mind, it is then 
a serious symptom, and should be at once reported to 
the physician in charge. Pregnant patients should wear 
loose and easily fitting slippers and stockings, all constric- 
tion about the limbs and waist should be avoided, and if 
the patient be easily fatigued she should take frequent 
intervals of rest in the recumbent posture. By this 
means swelling of the feet and limbs can be largely 
avoided. When such a condition is attended by obstinate 
itching, frequent bathing with cold water and in some 
cases bran foot-baths are especially efficacious. 



CHAPTER III. 

NURSING IN THE COMPLICATIONS OF 
PREGNANCY. 

Fecal Impaction. — Cases sometimes arise in early 
pregnancy in which the uterus becomes displaced, and by 
its pressure against the rectum produces chronic reten- 
tion of feces. In these cases the patient has considerable 
suffering, not only from constipation, but also from the 
pain and pressure-symptoms which the position of the 
uterus and the presence of hardened feces create. In 
these cases it is necessary to empty the intestine not only 
by purgatives and laxatives, but also by mechanical 
means. 

The physician in charge will usually prescribe such 
medicines as will render the feces thoroughly soft. The 
patient's diet should be suitable for the occasion, there 
being not much meat, but a considerable quantity of 
vegetables and fruit. A free supply of water is also 
necessary for these cases. 

The mechanical relief of these patients is obtained by 
injections adapted to softening the feces and to remove 
them in a partially liquid state. It is occasionally neces- 
sary to extract with the fingers portions of hardened mat- 
ter which otherwise could not be brought away. 

In using injections for these patients care must be taken 
that the injections should not be too hot nor too cold, 
and that they be administered as gently as possible, as 

37 



38 NURSING IN COMPLICATIONS OF PREGNANCY. 

undue violence might result in the production of abor- 
tion. The simplest sort of injection is very dilute warm 
Castile soapsuds. This is useful for cleansing purposes, 
but is not well adapted to soften hard fecal matter. At 
least one quart would be necessary, and this should 
be given at a temperature of 100° F., by means of a 
fountain-syringe, the patient lying upon her left side, and 
having the hips higher than the rest of her body. Where 
it is desired to introduce the fluid as high as possible in 
the bowel, it is well to employ a large-sized soft catheter, 
passing as far into the bowel as possible. The patient 
should be encouraged to retain the fluid as long as possi- 
ble, and when the inchnation for movement occurs the 
injection may be repeated, when the bowel will usually be 
emptied without much difficulty. 

Preparations of oil are especially valuable in cases of 
obstinate constipation. It is not, however, easy to convey 
the oil without mixing it with some suitable vehicle. 
Either castor oil or olive oil may be employed, and the 
following combination has been found most useful : 

Castor oil or olive oil, i ounce ; 

Castile soapsuds (at a temperature of 

100° F.), I quart. 

Mix together as thoroughly as possible; add 
spirits of turpentine, i dram, thoroughly 
beaten up with the yolk of i raw ^gg. 

This combination makes an unirritating and exceed- 
ingly efficient injection. If this does not run readily 
through a fountain-syringe, a smoothly working piston- 
syringe should be employed. Care should be taken to 
give the injection very gently, using as little force as 
possible and disturbing the womb as little as possible. 



FECAL IMPACTION. 39 

Saline injections are sometimes given in combination 
with glycerin. The following is a useful formula : 

Magnesium sulphate, 2 ounces ; 

Glycerin, 2 " 

Spirits of turpentine, \ ounce ; 

Warm water, i quart. 

Unless the case is a very obstinate one, however, 
injections containing oil should be preferred to this, lest 
the energetic action of this combination should excite 
uterine contractions. 

When it is necessary to soften the hardened fecal mat- 
ter ox-gall is often dissolved and injected, and allowed 
to remain for several hours before the bowels are moved. 
The following combination has been found useful : 

Pow^dered ox-gall, \ ounce ; 

Olive oil, I " 

Water (temperature 105° F.), i pint. 

Thoroughly mix. A piece of Castile soap is then 
stirred about in this mixture, to make a light lather. 
The whole when thoroughly mixed is at a temperature 
of 100° F., which is suitable for the purpose. It should 
be injected as high into the bowel as possible through a 
large-sized soft catheter or flexible tube, the finger being 
inserted into the bowel before the introduction of the 
tube. If the patient's pelvis be raised considerably, it 
will assist in obtaining a good result. If care be used, 
the patient should suffer no discomfort, and should be 
able to retain the injection for several hours. 

In giving injections to remove hardened feces, when 
it is desirable to carry the material injected high into 
the bowel, the knee-chest posture is often niost advan- 



40 NURSING IN COMPLICATIONS OF PREGNANCY. 

tageous. The patient may assume this either before the 
injection is given or just after. A few moments of this 
posture aids very greatly in promoting the passage of an 
enema high into the intestines. When it is inconvenient or 
uncomfortable for the patient to assume this posture she 
may lie upon her back with the hips considerably raised 
by folded blankets or pillows, or she may lie upon her left 
side with the hips raised. In either case the result is good. 

Considerable time is necessary for the thorough empty- 
ing of the intestine, because fecal matter is not readily 
softened. In some cases the softening material may be 
given at bedtime, and an injection for cleansing the 
bowel administered on the following morning. In other 
cases several injections during the day are necessary for 
this purpose. It has been said that great care must be 
taken in giving these injections that uterine contractions 
are not excited and that no undue force is used. Tubes 
employed for this purpose should be cleansed by boiling 
in soapsuds or by rinsing in hot soda solution. 

In addition to injections for emptying the bowel, sup- 
positories are often useful. Such are made of gluten or 
of glycerin, and may be inserted two hours before the 
administration of an injection. 

Pernicious Nausea. — Pernicious nausea of preg- 
nancy is a condition in which the patient is profoundly 
depressed and nauseated during her waking hours. In 
many cases food is rejected so soon as swallowed, and 
beverages are also rejected by some patients. The matter 
vomited consists at first of the food swallowed, then of a 
thin and glairy mucus, and finally, in fatal cases, of a 
dark coffee-ground-looking material. Patients usually 
lose rapidly in weight, become profoundly prostrated, 
and in some instances die of exhaustion. ' 



PERNICIOUS NAUSEA. 4 1 

In nursing these patients it is of great importance that 
a cheerful and encouraging mental influence be exercised. 
The words "nausea" and "vomiting" should not be 
mentioned to the patient. She should not be given a 
basin or a towel in which to vomit, as many nervous 
patients are made sick by such a suggestion. These 
cases are put to bed by the physician in attendance, and 
every effort made to support the strength of the patient, 
hoping that the nausea may cease. External warmth is 
applied if necessary by hot bottles and suitable covers. 
All depressing and disturbing influences are removed, 
and the patient's room should be bright and cheerful, and 
her attention should be diverted if possible from herself 
in any agreeable manner. She should have a soap-and- 
water sponge-bath once daily, and once daily a light mas- 
sage, or an alcohol-and-water sponge, or massage accom- 
panied by the inunction of olive oil. The mouth and 
teeth should receive attention, as patients are sometimes 
greatly annoyed by the formation of sordes and a very 
foul condition of the tongue. The mouth may be cleansed 
with boric-acid solution, with dilute thymol, with lemon- 
juice, glycerin and water, or with ice-water and a little 
alcohol. The patient should be catheterized if necessary, 
although she can usually leave her bed to use a commode. 

The direct treatment of these cases consists in the ad- 
ministration of drugs ordered by the physician, and given 
by the mouth, by hypodermic injection, or by rectal 
mjection. The nurse will receive precise orders from the 
doctor as to the times and modes of medication. 

Other methods of treatment sometimes employed are 
the washing out of the stomach and the use of electricity. 
To assist the physician in washing out the stomach, the 
nurse must have ready several pitchers containing water at 



42 NURSING IN COMPLICATIONS OF PREGNANCY. 

a temperature of from ioo° to 105° F., a slop-jar, sodium 
bicarbonate, and sodium chlorid, a rubber stomach-tube, 
a funnel, a piece of rubber sheeting, glycerin or olive oil 
for lubricating the tube, and an abundant supply of clean 
towels. If the tube be cooled by ice before passing, it 
is less Hkely to cause nausea. The physician will give 
precise directions as to the nature of the fluid to be em- 
ployed in washing out the stomach. He will introduce 
the stomach-tube, and the nurse will pour through the 
funnel the fluid which she has prepared at his request. 
It is sometimes necessary to keep the patient's teeth 
apart by folding a soft napkin into a wedge or cushion 
which is placed between the molar teeth. When this is 
in position the nurse may be asked to hold it in place. 
The effort is sometimes made after washing out the stom- 
ach to pour through the tube broth or soup, in the hope 
that it may be retained. 

To use electricity in these cases, the nurse should be 
competent to take care of the battery employed, unless 
the physician brings it with him for each application. 
The nurse will require a basin of warm water, absorbent 
cotton for covering the electrodes, and in some cases a 
little salt in addition. One electrode is usually placed 
over the epigastrium, or pit of the stomach, while the 
other is placed at the back of the neck. The duration 
of the application and the strength of the current must 
be regulated by the physician in attendance. 

It is sometimes deemed advisable in these cases to try 
the effect of hypodermoclysis or intravenous transfusion 
of saline fluid. Here the nurse must remember that 
needles or cannulas employed should be boiled before 
they are used, and that the skin should be made aseptic 
before either method of procedure is carried out. The 



PERNICIOUS NAUSEA. 43 

fluid to be introduced must have been sterilized by boil- 
ing, and the physician in charge must give precise direc- 
tions as to the amount of sodium chlorid or sodium 
bicarbonate which he desires the nurse to prepare. After 
the introduction of fluid in this way the point of puncture 
or incision into the vein must be protected by a light 
sterile dressing until it has perfectly healed. 

T\i^ preparation of food for these patients requires the 
most painstaking attention. It is seldom possible to use 
sohds, and barley-water, beef-juice, chicken-, mutton-, and 
beef-broths must be employed instead. Milk cannot be 
used unless pancreatized or peptonized, and in many 
cases in combination with barley-water or lime-water. 

Barley-water. — Put one tablespoonful of washed pearl 
barley in a saucepan with one pint of water. Boil in 
double boiler slowly for four hours. Strain through 
fine wire sieve. The following directions for preparing 
barley-water and other broths are original, we believe, 
with Starr : 

Barley-water. — Put two teaspoonfuls of washed pearl 
barley in a saucepan with a pint of water ; boil slowly 
down to two-thirds of a pint ; strain. 

Raw Beef-juice. — Take one pound of sirloin of beef, 
warm it in a broiler before a quick fire, cut into cubes of 
about one-quarter of an inch, place in a lemon-squeezer 
or a meat-press and forcibly express the juice ; remove 
the fat that rises to the surface after cooling. Never 
actually cook the meat. 

Chicken-broth. — A small chicken or half of a large 
fowl, thoroughly cleaned and with all the skin and fat 
removed, is to be chopped, bones and all, into small 
pieces ; put them, with salt, into a saucepan, and add a 
quart of boiling water ; cover closely and simmer over a 



44 CURSING IN COMPLICATIONS OF PREGNANCY. 

slow fire for two hours ; after removing, allow to stand, 
still covered, for an hour ; then strain through a sieve. 

Mutton-broth. — Add one pound of loin of mutton to 
three pints of water ; boil gently until very tender, add- 
ing a little salt ; strain into a basin, and when cold, skim 
off fat. Warm when serving. 

Beef-broth. — Mince one pound of lean beef, put it with 
its juice into an earthen vessel containing a pint of water 
at 85° F., and let it stand for one hour ; strain through 
stout muslin, squeezing all juice from the meat; place 
this liquid on the fire, and while stirring briskly slowly 
heat just to the boiling-point ; then remove at once and 
season with salt. 

It is well to feed by the stomach at the hours of dinner 
and luncheon, continuing rectal feeding during the night 
and morning. As soon as the patient can take an ounce 
of broth she will usually enjoy a little stale bread soaked 
in the broth, or livers of one or two raw oysters, or part 
of an ^g^ beaten up with milk or brandy. The patient 
should not be asked whether she desires food, nor should 
she know what is to be given her ; nor should food be 
kept where she can see or smell it. 

In cases in which the patient retains very little or no 
food when given by the stomach, feeding by the bowel 
must be employed. The success of this method of treat- 
ment depends not only upon the selection of the proper 
materials and their careful preparation, but also upon the 
care with which the injections are given and the especial 
attention to cleanliness which these cases demand. The 
most successful results are obtained with materials which 
a nurse can prepare. There are many preparations in 
market especially recommended for this purpose, but 
they are not so uniformly successful. Among those 



PERNICIOUS NAUSEA, 



45 



which are often employed are peptonoids, panopeptone, 
somatose, various beef-juices, and other similar prepara- 
tions. The following formulae have been found most 
useful : ^ 



I. 


Beef-tea, 


3 ounces ; 




Yolk of I raw egg ; 






Brandy, 


1 ounce ; 




Liquor pancreaticus, 


2 drams. 


2. 


I whole raw ^^^ ; 






Table-salt, 


15 grains; 




Peptonized milk, 


3 ounces ; 




Brandy, 


\ ounce ; 


3. 


Beef-tea, 


2 ounces ; 




Brandy, 


\ ounce ; 




Cream, 


^ * " 


4- 


Beef-tea, 
I whole raw ^%%. 


2 ounces ; 


5. 


Beef-juice, 


I ounce. 


6. 


Beef-essence, 


6 ounces. 


7- 


Whites of 2 raw eggs ; 






Peptonized milk, 


2 ounces ; 



2 eggs. 



To give nutrient injections successfully, the material 
employed must be at a temperature of 100° F., and 
should be introduced by a piston-syringe, which works 
perfectly smoothly, through a soft catheter carried very 
gently as far into the bowel as possible. A funnel con- 
nected by rubber tubing with the catheter may be used. 
The patient should lie upon her left side with the hips 

1 The writer is indebted for these formulae to Miss M. E. Smith. 



46 NURSING IN COMPLICATIONS OF PREGNANCY. 

raised. She should be urged not to strain nor bear down, 
but to endeavor to retain the material injected. Nutrient 
injections are given as a rule at intervals varying from 
four to eight hours. Unless the tubes employed are 
kept surgically clean and the rectum is washed out daily 
with sterile water, inflammation of the bowel may result, 
when the patient will fail to retain the injections. It is 
best to cleanse the bowel each morning by a copious but 
gentle enema of very mild soapsuds, followed by boiled 
water. Tubes used for rectal feeding should be boiled 
once or twice daily, and when not in use should be kept 
in a solution of boric acid. To lubricate these tubes, 
sterile glycerin or sterile olive oil should be used. 

It is sometimes thought desirable to add medicines to 
rectal injections. This is done under the precise direc- 
tions of the physician in charge, those substances being 
selected which are most easily dissolved and least likely 
to irritate the mucous membrane of the intestine. In 
addition to feeding and medication by rectal injections, 
nutritious material and medicine are sometimes placed in 
large gelatin capsules, which are introduced within the 
bowel and allowed to dissolve, when the food or medicine 
is absorbed. 

A small amount of nutritious matter can be intro- 
duced within the body by inunction in these cases. To 
accomplish this, the skin must be kept in good condition 
by sponging with warm soap and water, and by frequent 
hght massage. The best time for inunctions is after the 
soap-and-water sponge-bath. The materials employed 
may be sterile olive oil, or olive oil (two parts) and alcohol 
(one part), or sterile cocoa-butter. From one to four 
drams of fat may be rubbed into the body by gentle but 
patient manipulation. The patient's strength is undoubt- 
edly increased by such treatment. 



TOXEMIA OF PREGNANCY. 47 

Cases of pernicious nausea sometimes develop bed- 
sores very rapidly. To avoid this the patient should be 
turned frequently upon the side, the skin should be kept 
in good condition by frequent bathing, and when indica- 
tions of a bed-sore appear pressure should be removed 
by the application of rings of adhesive plaster or com- 
presses of powdered baked starch, or other methods 
applicable to prolonged and wasting disease. 

In some of these cases the cause of the pernicious 
nausea is found in some abnormal condition of the 
womb. This may be remedied by local treatment, and 
the nurse in charge of such a case should be prepared to 
assist the physician in such treatment. She will require 
an abundant supply of hot water, antiseptics, surgical 
cotton or prepared wool, and in many cases antiseptic 
gauze ; in some cases applications may be made of iodine 
or some other medicinal substances. To assist the phys- 
ician in the treatment of such a case the nurse should 
understand the various postures used for such treatment 
and the various methods employed. In severe cases it 
is especially valuable to the attending physician to have 
complete notes kept by the nurse, giving an accurate 
summary of food and stimulants retained during the 
twenty-four hours. Unless the patient improves, it may 
be necessary to terminate pregnancy by an operation to 
save the mother's life. 

Toxemia of Pregnancy. — During pregnancy the 
quantity of waste material formed in the body of the 
mother is considerably increased, and in addition she 
must excrete or discharge the waste material formed in 
the body of the fetus. If this process of elimination is 
not complete, the patient will suffer from the poisonous 
effects of the retained materials The symptoms of such 



48 NURSING IN COMPLICATIONS OF PREGNANCY. 

poisoning are headache felt severely above the eyes, dul- 
ness and lassitude; constipation; failure to perspire; and 
a scanty secretion of urine, usually accompanied by a 
furred and coated tongue. In some patients severe neu- 
ralgia accompanies the headache. If this condition be 
allowed to go unrelieved, it may terminate in eclampsia, 
which may prove fatal. 

A patient with the symptoms just described should 
consult a physician at once. The treatment employed 
in this condition calls for active movement of the bowels, 
and the duties of the nurse would lie in administer- 
ing medicines ordered and in giving purgative enemas. 
The combination of magnesium sulphate, glycerin, tur- 
pentine, and soapsuds, which has been given, would be 
found especially useful in such cases. The physician 
may prescribe sedative medicines for the cure of the 
headache, although these are of Httle importance in the 
cure of the case. The patient's diet is usually restricted 
as nearly as possible to milk ; and as this often proves 
tedious, the nurse would be called upon to prepare vari- 
ous milk-foods which might prove palatable. Such are 
junket (made by curdling milk with rennet ferment), 
koumiss, light milk-puddings, custard, peptonized and 
pancreatized milk, buttermilk, and in some cases a small 
quantity of cottage-cheese is allowed. In suitable cases 
ice-cream may be made for the patient, using a minimum 
of sugar and ^gg, and employing the greatest possible 
quantity of cream and milk. Well-made toast thor- 
oughly softened is usually allowed. This is often served 
with milk or cream. Ripe fruit, raw or cooked without 
sugar, and the most digestible green vegetables, are fre- 
quently ordered. 



TOXEMIA OF PREGNANCY. 49 

With these patients the action of the skin must be thor- 
oughly roused. The patient may be given a hot tub- 
bath, and while in the bath may be asked to drink several 
glasses of water as hot as it can be borne. This will 
usually cause free perspiration. In other cases the pa- 
tient is given a hot pack or a steam or vapor bath. If a 
nurse be put in charge of such a patient, she would be 
expected to measure accurately the amount of urine 
passed, and to send specimens frequently for examina- 
tion. She would also be expected to follow strictly the 
diet prescribed, and to carry out carefully the physician's 
directions in the matter of bathing. 

Water is usually given very freely to such patients. 
The quantity is often definitely prescribed, and the nurse 
must see to it that the directions are carried out. 

Care must be taken that the patient has at all 
times an abundance of fresh air, avoiding chill and 
damp. 



CHAPTER IV. 

LABOR, DESCRIPTION OF AND PREPARATIONS 
FOR. 

Labor is that process by which the child is removed 
from the body of the mother. In natural, spontaneous 
labor the mother expels the child by the contractions of 
the uterus and abdominal muscles. When these forces 
fail the child may be removed from the body of the 
mother by various surgical procedures. 

Labor also includes the removal not only of the child, 
but its appendages as well. These are the placenta, the 
membranes, the umbilical cord, and the amniotic liquid. 
If any one or part of these is retained, the labor is in- 
complete. 

This process must be a gradual one for the safety of 
mother and child, and may be conveniently divided into 
periods or stages. The first stage of labor extends from 
the first regular contractions of the uterus to the time 
when the neck and mouth of the womb dilate or open. 
The second stage of labor is occupied with the expulsion 
of the fetus ; and the third stage comprises the removal 
or expulsion of the fetal appendages. 

The accurate recognition of labor is an important 
matter which comes within the province of the nurse. If 
the patient be wrongly supposed to be in labor, the 
attending physician may be called unnecessarily, the 

50 



PAINS. 5 1 

patient unduly excited and alarmed, and much valuable 
time wasted. Upon the other hand, if the beginning 
of labor is not recognized, the patient may be suddenly 
taken with violent expulsive pains, and the child may be 
delivered before assistance can reach her. The recogni- 
tion of labor can best be accomplished by considering 
carefully the various phenomena which make up this 
process. 

Pains. — The symptom of labor which is noticeable 
to the patient is pain in the lower portion of the body. 
In the first stage of labor this pain begins in the back 
in the lower third of the spinal region, and extends 
gradually around the body to the front, or pubic region. 
Together with these there are slight cutting sensations 
deep in the pelvic region, and a discharge, varying in 
quantity, of mucus slightly tinged with blood. Irritation 
of the bladder and rectum is also present, the patient 
desiring to empty the bladder very frequently. In 
some cases nausea and vomiting occur. The pains of 
labor result from uterine contractions ; and although 
these contractions have been going on at intervals 
during pregnancy, they have been irregular, and would 
cease if the patient remained quiet. Labor-pains, how- 
ever, come at fairly regular intervals, and tend steadily 
to increase in vigor and in the severity of the suffering 
which accompanies them. 

Other causes than labor may produce pain in the 
abdomen. For example, intestinal colic is a frequent 
source of abdominal pain. This may follow the eating 
of indigestible food, the drinking of very cold fluids, or the 
formation of gas in the bowel through nervous appre- 
hension ; and in some rare cases the pain may be the 



52 LABOR. 

result of neuralgia or rheumatism in the muscles of the 
abdomen. 

Recognition of I^abor. — To tell that a patient is in 
labor or is not in labor, the nurse should first wash her 
hands thoroughly with warm water and soap, and then 
should place the patient upon a comfortable bed or 
couch, upon her back with the thighs drawn up. If 
labor be beginning, the womb can be felt by the hand 
laid upon it to contract and then to relax at fairly regular 
intervals. If labor is not beginning, however, uterine 
contractions will not be especially noticeable. 

The nurse can judge fairly well of the course and 
progress of labor by the regularity and vigor of the 
uterine contractions. She should in all cases take the 
precaution to ascertain from the physician when he 
wishes to be summoned. If this be understood, the 
nurse will send for the doctor upon plain and positive 
indications, and thus will save an unnecessary expendi- 
ture of his time. It is often difficult to persuade patients 
that the first pains of labor are not of the greatest im- 
portance. It is especially hard to persuade them to have 
patience during this part of labor, because they cannot 
recognize that progress is being made. In sending for 
the physician, the nurse should tell how long the pains 
have been going on, at what inter\^als, and how strong 
they are. By sending as much information as possible 
with the message the doctor can often plan his course in 
such a way as to give every attention, and -yet not inter- 
fere unduly with his work. 

First Stage. — Th^ duration of the first stage of labor 
varies greatly. In young patients pregnant for the first 
time the first stage of labor may last from twelve to 
more than twenty hours. The patient will not be in 



SECOND STAGE. 53 

active paih all this time, and may be able to eat and sleep 
quite comfortably. 

The first stage of labor comes more under the care of 
the nurse than any other portion of labor. There is 
little or nothing which the physician can do for his 
patient, and hence it is better that he should not be in her 
presence or near at hand at this time. Many patients 
ask constantly for sedative and anodyne drugs to relieve 
their s-uffering. If these are given, the course of labor is 
delayed, and hence the patient's suffering is prolonged. 
Unless it is necessary to bring on sleep, careful physi- 
cians rarely gwt sedative drugs during the first stage of 
labor. Hence the patient relies very largely upon the 
encouragement and care which the nurse gives her during 
this prolonged and tedious time. 

Second Stage. — The bursting of the waters, or rupt- 
ure of the membranes, marks the end of the first and the 
beginning of the second stage of labor. This often 
occurs suddenly, and the quantity of fluid discharged 
may vary from a few ounces to one or even several quarts. 
In young patients considerable alarm may be felt when 
the membranes rupture, through lack of knowledge and 
experience of what is happening. In some cases it is 
impossible to tell when the membranes rupture ; the dis- 
charge of fluid is so slight as to be unnoticed. In other 
cases the membranes are so tough and resisting that they 
do not break naturally, but are ruptured artificially by the 
physician. When rupture occurs labor usually proceeds 
much more actively. The pains become more severe, 
uterine contractions are stronger, the patient is roused to 
exert herself by straining, pressing, and bearing down to 
assist in the birth, and the child usually moves steadily 
downward through the body of the mother. The second, 



54 LABOR. 

or expulsive, stage of labor varies in duration from a few 
moments to several hours. On the average it is about 
two hours in length. During this time the patient has 
strong contractions of the womb, coming at regular 
intervals and followed by periods of absolute quiet and 
relaxation. During the uterine contractions the face 
becomes flushed, the heart beats very strongly, the patient 
often perspires, and there is abundant evidence that great 
muscular exertion is taking place. In the intervals 
between the contractions of the womb and abdominal 
muscles the patient will often rest quietly and sometimes 
doze. This is Nature's protection against exhaustion ; 
and when the patient does not rest between the pains she 
is evidently in danger of becoming thoroughly tired out. 
As the child descends through the pelvis, when uterine 
contractions occur the womb rises in the abdomen, pro- 
jecting downward and forward, and becoming exceedingly 
hard and resisting. When the child reaches the pelvic 
floor and the presenting part comes against the muscular 
and elastic tissues and the mucous membrane of this 
region, the pressure of the child against the nerves of this 
portion of the body greatly increases the patient's suffer- 
ing, and brings about more violent contractions of the 
womb ; the patient complains of a tearing, pressing, or 
rending sensation -; the perineum bulges ; the mucous 
membrane about the anus becomes dark reddish and 
sometimes projects, and if the bowel has not been 
thoroughly emptied before labor fecal matter is often 
pressed out. As "birth proceeds the scalp of the child 
becomes visible in the vulva, the pains seem to in- 
crease in violence, the parts become greatly distended, 
and finally the head of the child is born, the face 
being directed downward and backward and the 



SECOND STAGE. 



55 



occiput, or vertex, being directed upward and forward 
(Fig. 8). 

When the head has been born there comes a cessation 
of a very few minutes in the labor ; and then the patient 
has further uterine contractions, and the shoulders and 
body of the child are born. The arms are usually folded 
across the chest and the forearms flexed upon the arms. 




Should this not be the case, but should the arms drop 
dow^nward away from the child's chest, the point of the 
elbow may tear the mother considerably as it emerges. 

There usually occurs with the child the passage of a 
part of the amniotic liquid which has been kept in the 
womb by the pressure of the child's body. The child 
usually turns upon its side in the mother's bed, and very 
often begins to cry so soon as born. It is still connected 
with the body of the mother by the umbilical cord, which 
continues to pulsate, and through which blood passes 



$6 LABOR. 

from the mother to the child. This pulsation gradually 
ceases in from five to ten or fifteen minutes ; and when 
the pulsation ceases, if the child does well, it cries or 
moves more vigorously. Very little discharge of blood 
follows the birth of the child if the labor is natural. The 
mother lies still, being exhausted with the efforts of par- 
turition, and the uterus remains large, although well con- 
tracted, because it still contains the after-birth, or placenta. 

Third Stage. — When the cord has ceased to pulsate, 
it is tied by two ligatures and cut between them, and the 
child is taken away. A pause of from fifteen minutes to 
half an hour occurs after the expulsion of the child, 
during which the mother lies perfectly quiet. She some- 
times experiences a slight shiver or chilliness, which is 
not a septic rigor, but which is caused by the cessation 
of the great muscular effort which she has made. Finally 
there occurs the return of uterine contractions, and a 
second, smaller labor takes place. The pains come on 
again at regular interv^als and are not very severe, the 
uterus contracts, there is a very slight flow of blood, and 
then the edge of the placenta appears in the vulva. If 
the uterus contracts well, the placenta is expelled entirely, 
the membranes coming after it in a rope or strand. There 
is but little bleeding, the womb remains well contracted, 
and the labor has ended naturally. 

Preparations for I^abor. — From our study of labor 
we see that it is a process which exposes the mother to 
wounds and lacerations in the genital tract, and that the 
separation of the placenta leaves a wound as large as a 
small saucer within the womb. Our knowledge of wounds 
and their healing teaches us that the parturient patient is 
exposed to the dangers of wound infection, or, in other 
words, to puerperal sepsis. We also know that if the 



PREPARATIONS FOR LABOR. 57 

uterus does not contract the patient will suffer from 
bleeding, and that if she be extensively torn in child- 
birth, bleeding may occur from ruptured vessels. If we 
are to care properly for the patient, she must .have 
the same treatment which patients receive upon whom 
surgical operations are performed. There must be aseptic 
or antiseptic dressings to protect this patient from wound 
infection. Hemorrhage must be prevented or checked, 
and lacerations in the birth-canal will require closure by 
suture. This is especially true in cases in which labor 
has terminated by the use of instruments, when the birth 
becomes a distinctly surgical operation. In addition to 
proper dressings the nurse must be prepared to take 
antiseptic precautions regarding her hands, her clothing, 
and any articles which she may use about the patient. 
There must also be at hand stimulants and anesthetics 
for a surgical procedure. While in natural birth assistants 
are not often required, in operative cases the physician 
needs an assistant to give ether, just as he would for a 
surgical procedure. Nurses who prepare themselves for 
surgical work do not expect to attend cases of infectious 
disease, and if they have a septic case are exceedingly 
careful to disinfect themselves before going to another 
operation. So the obstetric nurse must avoid infectious 
diseases, and thoroughly disinfect herself before going 
from a septic to a non-septic confinement. 

In addition to preparations for the care of the mother, 
the child must be considered. Precautions must be taken 
to avoid infection in the child's body at those places at 
which it is most apt to occur. Its clothing must be 
provided, and it often requires a considerable degree of 
warmth. 

Dressings. — In providing praper dressings for a patient 



58 LABOR. 

to be confined, the question of expense and of the work of 
the nurse engaged must be considered. Suitable dressings 
may be procued in one of two ways : Antiseptic gauze 
can be obtained at drug-stores and instrument-shops, 
from which dressings can be made. Such gauze, how- 
ever, costs more than simpler dressings. If the patient 
desires to avoid this expense, and if she will compensate 
the nurse, the nurse can prepare dressings which are 
aseptic or can be made antiseptic at small cost. The 
choice of the method of preparing dressings should be 
left to the patient, and inust be determined somewhat 
by the circumstances of the case. 

A cheap and comfortable dressing is made from 
absorbent cotton and the cheaper quality of cheesecloth. 
Two thicknesses of the cotton as rolled are taken in a 
piece seven inches long and five inches wide. Each roll 
furnishes cotton sufficient for thirty-eight dressings. This 
piece of cotton is enclosed in one-quarter of a yard of 
cheesecloth, so folded as to be eighteen inches long and 
five inches wide. A roll of cotton can be purchased for 
thirty-five cents, and cheesecloth costs five cents per yard. 
The number of dressings required will vary somewhat 
with the nature of the patient and the character of the 
case. As a rule, dressings must be worn for two weeks. 
Making a very liberal estimate of the number which may 
be required, the cost of the simple dressings described 
will approximate two dollars. The preparation of these 
dressings is the work of the nurse who is to attend the 
patient in confinement. Dressings may be either sterilized, 
or may be sterilized and made antiseptic as well. In the 
former instance the dressings are made with clean hands, 
and the edges of the cheesecloth are run together with a 
simple stitch. It may not be convenient to make the 



PREPARATIONS FOR LABOR. 59 

entire quantity required at first, but sufficient may be 
prepared for the first week of the lying-in period. Three 
or four dozen are an ample supply for this purpose. These 
should be put into a clean old pillow-case or wrapped in 
an old sheet, and the bundle put into an oven and the 
dressings baked for as long a time as convenient. They 
should be left in the sheet or pillow-case, wrapped in a 
large clean sheet of wrapping-paper, labelled, and put 
away until required. 

When it is desired to use cheap antiseptic dressings, 
they may be prepared in the manner described, the nap- 
kins dipped in a solution of mercuric chlorid (i : 2000), 
then dried, and baked in addition. Cheesecloth as pur- 
chased from the shops often contains stiffening material, 
which is designed to make it lie smoothly in the piece. 
This must be removed before the cheesecloth is ready for 
use as a surgical dressing. A ready method of accom- 
plishing this consists in boiling the fabric in water to which 
sodium bicarbonate has been added, rinsing it in clean 
boiled water, and either drying it, or soaking it in bichlorid 
solution, after which it can be dried and cut into conven- 
ient lengths. 

In addition to material for vulvar dressings, bandages 
will be required for the abdomen and also for the breasts 
(Fig. 9). Unbleached muslin is usually selected for this 
purpose. Sufficient should be purchased to make from 
half a dozen to one dozen abdominal binders, and from 
half a dozen to one dozen bandages for use in dressing 
the breasts. The abdominal binder should be forty-seven 
inches long, of double thickness, hemmed at the edges, 
and fifteen inches wide. The breast bandage should be 
on the average forty inches long and ten inches or more 
in width. In choosing rubber sheeting to protect the 



6o LABOR. 

mattress, double rubber sheeting should be obtained if 
possible. Unbleached muslin costs about ten cents per 
yard, while rubber sheeting costs about one dollar per 



1 




p 

1 


' 


k 


i 













Fig. 9.— Breast bandage and abdominal binder. 

yard. Two pieces, one yard square, should be obtained 
if the patient can afford them. Leggings are used in 
some maternities during operation, and laced and but- 



PREPARATIONS FOR LABOR. 6 1 

toned breast and abdominal bandages are employed by 
some (Fig. lo). 

When a patient wishes to economize, clean old linen 




Fig. io. —Leggings for use during operations ; laced and buttoned bandages for breasts 
and abdomen. 

may be employed to good advantage. This is soft, 
and may be sterilized by boiling or baking, and made 
antiseptic by soaking in antiseptic solutions. With cotton- 
batting it can be used in place of cheesecloth. To give 



62 LABOR. 

firmness to vaginal dressings, a little oakum may be 
placed in the center, inclosed in the cotton. 

Medicines. — In addition to dressings, some medicines 
are necessary, and may be obtained upon the physi- 
cian's order from the druggist. Such are : Fluid extract 
of ergot, one ounce ; brandy, two ounces ; sterile boric- 
acid solution, one pint ; lysol, three ounces ; fifty tablets 
of mercuric chlorid, of which one to the pint equals 
I : looo. 

The following lists are those which we are accustomed 
to give to patients. One of these calling for antiseptics 
and other drugs, and prepared gauze, should be sent to 
a druggist, who will put up the articles in one large 
package, to remain unopened until they are needed. 

The other list comprises articles which the nurse 
should prepare at the patient's home. 

List of Articles to be Fiirriished by a Druggist for 
Confinement Cases. — Fifty tablets bichlorid of mercury, 
one to the pint equals i : lOOO ; lysol, six ounces ; bi- 
chlorid gauze, five yards in glass jar ; borated cotton, 
one large box ; sterile saturated solution boracic acid, 
one pint ; one large new fountain-syringe ; double rubber 
sheeting, two yards ; one medium-sized, soft catheter ; 
one glass catheter ; two stiff nail-brushes, with wooden 
backs ; one new medicine-dropper ; Squibb's fluid extract 
of ergot, one ounce ; Squibb's ether for anesthesia, two 
half pounds ; brandy, two ounces ; tincture green soap, 
eight ounces ; one box containing tubes of aseptic ergot, 
Parke, Davis & Go's ; twenty tablets, each containing 
sulphate of strychnia, 1-40 gr. 

List of Articles for Confinement to be Prepared by the 
JSJiirse. — Three good-sized basins ; three good-sized 
pitchers ; six sterile sheets ; two dozen sterile towels ; 



PREPARATIONS FOR LABOR. 63 

one dozen breast binders ; one dozen abdominal binders ; 
large package of dressings for external use ; sterile cot- 
ton sponges. 

Room for Confinement. — Whenever possible the nurse 
should give to her patient assistance in selecting and 
suitably arranging a room for confinement. This should 
be in as quiet a part of the house as possible, where sun- 
shine and air gain free access and, for the convenience of 
the nurse, on the same floor with a bath-room. The room 
should not have in it a stationary washstand nor any 
connection with pipes leading to a sewer. If possible, it 
should not have a register from a furnace opening into it. 
It is of great advantage if such a room have an open fire- 
place, in which a fire can be kept burning during cold 
weather. It is very convenient to have adjoining this 
room one or two smaller rooms for the use of the nurse 
and the child. 

The furniture should be as simple as possible, and it 
will be of great assistance to the nurse if a high and narrow 
bed can be used. A bed which is otherwise suitable, but 
too low, may be raised by placing a stout block of wood 
from eight inches to one foot high, under each leg. The 
mattress should be made of the best quahty of hair, and 
while agreeably soft it should be firm. Old hangings 
should be taken away from such a room and as little 
drapery as possible employed. If there is any record of 
illness in this room, it should be thoroughly cleaned and 
aired ; and if there has been a case of infectious disease 
the room should be thoroughly fumigated as well. Car- 
pet is unnecessary on the floor of the room unless the 
weather be very cold, and a few rugs are all that is needed. 
Any expensive or highly finished furniture should be 
removed, as it may become soiled or injured from anti- 
septics or other material employed about the patient. 



64 LABOR. 

Bed. — For the bed, there should be in readiness an 
abundance of linen which has been repeatedly boiled. 
Old linen is preferable, as it may become soiled, and it 
might be necessary to destroy it. Several pillows are re- 
quired, and an abundant supply of towels and bed-linen 
should be in readiness. For the confinement, the bed 
should be narrow and high, with firm mattress, and made 
up with a rubber draw-sheet covered by a white draw- 
sheet in the center of the bed, and above the first linen 
and draw-sheet there should be placed a complete second 
outfit. This enables the nurse to take away the soiled 
linen upon the under, or cleaner, outfit, leaving the 
patient comfortable. It is usually necessary to pin the 
draw-sheet and rubber sheet to the mattress with large 
safety-pins, to keep the sheet smooth beneath the patient. 

Basins and Clothing. — The nurse will require several 
basins and toilet pitchers, a plentiful supply of hot water, 
a large piece of new and pure Castile soap, several slop- 
jars, and a small clean agate or tin basin is also useful. 

The patient may utilize old underclothing for her con- 
finement. Unless the weather is very hot, she needs to 
wear Hght woollen or silk and wool undershirts. Old 
night-dresses are useful for this purpose, and they may 
be slit down the front or the back for ease of application. 
When the patient begins to sit up in bed dressing-sacques 
are useful, and when she begins to get up a wrapper or 
bath-robe or dressing-gown is useful. 

Some form of douche-pan or bed-pan will be needed. 
The ordinary earthen bed-pan usually answers the pur- 
pose, although agate-ware douche-pans are better. A 
commode will be needed when the patient begins to 
leave her bed. 

Ligatures. — In preparing for the child, the nurse is 



s^Ik 




'i 



-r" ^ ~- 



fm 



PREPARATIONS FOR LABOR. 65- 

often expected to provide ligature material for tying the 
umbilical cord. A thin, narrow tape, called bobbin, is 
sold in the shops, or a good Hgature may be made by 
tying several strands of coarse linen thread together, 
boiling them thoroughly, and keeping them immersed 
in boric-acid solution. Many physicians bring with 
them the material for ligating the cord, and boil it in 
the sterilizer, which they also bring. Various sorts of 
material are used for the cord, and it is well for the 
nurse to ask the physician his preference before the con- 
finement occurs. 

Baby-clothes. — The baby's outfit consists of toilet arti- 
cles and clothing. The former are usually arranged in 
a basket, known as a baby basket ; while the latter are 
generally prepared during pregnancy and put away in 
readiness. A simple but sufficient outfit for a baby would 
consist of the following : 

One dozen white slips. 

Six flannel slips with sleeves, for night. 

Six flannel slips with sleeves, for day. 

Six woollen woven shirts with long sleeves. 

Six knit abdominal bands. 

Baby's hair-brush. 

Powder-box and puff. 

Four dozen diapers, not too large, and made of cotton 
diaper, twenty-two inches wide. 

One dozen medium-sized safety-pins. 

Four soft wash- cloths. 

One dozen soft towels. 

Two bathing-aprons of flannel. 

Two light and soft shawls. 

One half-dozen to one dozen pairs of knit socks. 

Crib. — A crib, or bed, for the child is usually selected. 
5 



66 LABOR. 

This should be without rockers or swinging motion, 
should be plain and simple, and one which can if neces- 
sary be thoroughly cleaned. In cases in which it is 
desired to keep the child especially warm and to move 
it about readily, an ordinary clothes-basket lined with 
blankets and pillows makes an excellent temporaiy crib. 



CHAPTER V. 

THE DUTIES OF THE NURSE DURING THE 
PATIENT'S LABOR. 

The First Stage. — The first stage of labor is espe- 
cially that which comes under the care of the nurse. 
During this period there is Httle which the physician 
can do to expedite birth. Dilatation of the womb must 
take place, and very gradually to avoid injury, and this 
process occupies a number of hours. If, however, the 
patient is not properly cared for at this time, she may 
lose physical strength, become mentally exhausted and 
depressed, and the progress of labor be temporarily or 
permanently checked. The nurse must see to it that 
the bowels are thoroughly and gently moved by a copi- 
ous rectal injection. The formula which have already 
been given in treating of the constipation of pregnancy are 
suitable for this purpose. The bladder must be emptied 
at frequent intervals ; and should the patient not be able 
to accomplish this the use of the catheter is necessary. 
The catheter should be passed by direct inspection, the 
hands of the nurse having previously been cleansed with 
soap and water, rinsed in hot water, and then brushed 
with mercuric chlorid solution (i : 2000). The catheter 
should have been boiled for fifteen minutes. For preg- 
nant cases the soft-rubber catheter is safest ; the glass 
catheter should not be used, as the urethra is often 
subjected to considerable pressure and the glass catheter 
might wound the parts. With the catheter, boil six 



68 DUTIES OF THE NURSE DURING LABOR. 

cotton sponges to cleanse the parts. The tissues about 
the opening of the urethra should be thoroughly 
cleansed with sterile cotton and boiled water, and then 
with bichlorid solution (i : 4000). The catheter should 
be lubricated with sterile glycerin or sterile olive oil. 

Vaginal injections before labor should never be given 
without the precise order of the doctor. If douches are 
used, the physician should prescribe the medicament 
which is to be given, and the quantity and the tempera- 
ture at which the douche is to be used. He should also 
state clearly the number of douches to be given in 
twenty-four hours. 

In addition to emptying the bowel and bladder, if 
labor is just beginning, the patient should wash herself 
thoroughly with soap and water, washing the genital 
organs with especial care. Sponges should not be em- 
ployed, but wash-cloths which can be boiled should be 
used instead. Physicians sometimes direct the nurse to 
shave the hair which grows about the genital organs, 
or to cut it away as closely as possible with scissors. In 
addition to thorough washing of the external parts, they 
should be cleansed with sterile water and with such anti- 
septics as the doctor orders. Usually bichlorid of mercury 
I : 2000 is used. Her clothing should be arranged so as 
to be as comfortable as possible. In cold weather a thin 
woollen undershirt or vest, an old night-dress, a bed-room 
wrapper, woollen stockings, and easy slippers should be 
worn. In warmer weather lighter clothing is necessary. 
It is often customary to braid the hair in two portions, as 
it is thus most comfortable during the patient's labor. 

It is well to avoid a heavy meal of solid food at this 
time. As labor proceeds and the mouth of the womb 
opens the patient is frequently nauseated, and she may 



THE FIRST STAGE. 69 

be obliged to take an anesthetic during labor, when the 
presence of solid food in the stomach is very undesirable. 
The best food for this period of labor is that which leaves 
no residue in the stomach. Chicken-broth, mutton-broth, 
beef-juice, or other nourishing soups and broths, with a 
small quantity of bread, are suitable. An abundance of 
water should be taken, and a moderate quantity of tea 
or coffee if the patient desires it. 

If the labor is the first, during the early stage the 
patient should be encouraged to be up and about, 
because this favors the descent of the child. When 
pains occur she may lie down or sit, leaning the body 
forward and grasping a chair in front of her as a sup- 
port. As the pains increase in severity the patient will 
be forced to lie down until the birth occurs. Where the 
patient has had children previously, she cannot be up 
and about so long lest a precipitate birth should occur. 
So soon as active pains begin the patient will usually lie 
down in these cases. When the patient assumes the 
recumbent posture in natural labor she should lie upon 
the left side, the head and shoulders sHghtly raised, and 
the thighs flexed upon the body. This posture favors 
the descent of the fetus, and also its progress through 
the body of the mother. 

As many labors occur at night, the nurse should watch 
closely to see that the patient does not become exhausted 
from lack of sleep. When the pains are simply nagging 
without increasing steadily in vigor the nurse should 
report this fact to the physician, and thus give him the 
opportunity for prescribing something to give the patient 
rest. In some cases, where weakness is apparent, the 
physician will order stimulants at regular intervals during 
labor. They should not be given without his orders. 



70 DUTIES OF THE NURSE DURING LABOR. 

A most important function of the nurse during this 
part of labor is her mental control of the patient. Very 
frequently she is asked many questions about the course 
and progress of labor. She should give such explana- 
tions as good sense dictates, never relating anything of 
a depressing nature. She should never speak of possible 
complications or of severe cases which she has seen, nor 
of operations at which she has assisted or of remarkable 
recoveries from dangerous illness. Her attitude should 
be that of patience and hopefulness, while she must abso- 
lutely avoid the expression of her own opinion. She 
must also carefully abstain from stating the probable 
duration of labor, as this is something which no one 
can absolutely foretell, and regarding which the patient 
naturally desires information. 

As the first stage of labor draws to its close the nurse 
must utilize the time in preparing for the second, or 
active, portion. A plentiful supply of hot water must be 
always available. Stimulants, antiseptics, dressings, uten- 
sils, and the necessaiy articles for the child must all be 
in readiness. After the membranes rupture an anti- 
septic dressing must be worn over the vulva. Material 
should be in readiness for the cleansing of the doctor's 
hands, as upon his arrival he will usually make a vaginal 
examination. 

The Second Stage. — During the second stage anti- 
septics should be kept in constant readiness for the 
cleaning of the physician's hands, and also for cleans- 
ing the external parts of the patient at the time of 
examination. During the second stage of labor, the 
nurse must exercise especial caution to maintain thorough 
antisepsis in her hands and clothing. The hands should 
be repeatedly disinfected, and if a fresh dress is not worn, 



THE SECOND STAGE. /I . 

the clothing should be covered by a sterile gown or by a 
large sterile apron. Under no circumstances should the 
nurse introduce a finger within the vagina, and she 
should take especial precautions in cleansing the patient 
to introduce nothing within the birth-canal. The phy- 
sician is usually present at this time, and the nurse's 
duties consist in having needed articles ready, and in 
assisting the patient to sustain her strength. Many 
patients during the second stage of labor suffer from 
pain in the lower portion of the back, and frequently 
request the nurse to rub the back or support it by 
pressure. An anesthetic is often given to a very 
mild degree of anesthesia, and the nurse should be 
competent to assist in this. Just before the birth occurs 
the physician may give the anesthetic into the charge of 
the nurse, instructing her to use it freely at the moment 
when the head is born. If ether be employed, it should 
be given in small quantities constantly inhaled, care being 
taken that the lips and face of the patient are not irri- 
tated by the ether. If chloroform is used, much less is 
required to produce an effect. Cold cream or vaselin 
should be applied to the face before anesthesia. At the 
moment when the child is born the nurse should have 
in readiness a warm blanket ; ligature for the cord and 
scissors should also be ready. Many physicians have a 
hypodermic syringe filled with strychnin solution and 
another filled with aseptic ergot ready for use. When 
the child is born, the nurse should be ready to receive 
it in a warm blanket so soon as the doctor has tied and 
cut the cord. 

So soon as the head of the child is born a slight pause 
often occurs, and if the conditions are favorable the nurse 
may wipe the eyes of the child with a small square of 



72 DUTIES OF THE NURSE DURING LABOR, 

very soft linen soaked in a saturated solution of boric 
acid. So soon as the birth of the child occurs the physi- 
cian will allow a few moments to elapse before tying and 
cutting the cord. During this time it is well to wipe out 
the mouth of the child with soft Hnen soaked in boric- 
acid solution, that it may be freed from mucus, and that 
the child may not inspire mucus into its bronchial tubes. 
The discharge of matter from the mouth is much facili- 
tated if the child be held by its thighs and legs with the 
head downward. Some physicians prefer to crush the 
cord with forceps before tying it, and apply forceps to the 
placental end of the cord to control hemorrhage. Two 
pairs of forceps should always be in readiness for those 
physicians who prefer this practice. So soon as the child 
is born, the pillow may be removed from beneath the 
patient's head. She must be cautioned not to raise her 
head suddenly. 

The Third Stage. — During the third stage of labor 
the duties of the nurse are to have ready a plentiful 
supply of hot water, at least two quarts of such hot anti- 
septic solution as the physician orders, to have antiseptic 
dressings available, fluid extract of ergot, and usually 
the physician's hypodermic syringe is prepared for use. 
As the physician delivers the placenta the nurse should 
hold a basin in which a towel is laid under the patient's 
thigh, to receive the placenta. The physician will usu- 
ally remove clots from the vagina, placing them in the 
basin with the after-birth. When the placenta has been 
removed ergot is usually given, and any stimulant 
required, and the physician will examine the patient for 
lacerations. 

I/acerations. — The nurse should never undertake the 
responsibility of deciding that lacerations are present. 



^ 



DOUCHES. 73 

This is a most important matter, in which the nurse may 
bring upon herself just blame. If the physician requests 
her to tell him whether a laceration is present or not, 
she should respectfully decline to do so, saying that she 
is not competent to make the examination. If there are 
no lacerations requiring suture, the physician usually 
instructs the nurse to clean and dress the patient, and 
the puerperal period may be said to have begun. 

Douches. — Many doctors have one douche given 
after each labor, to wash out thoroughly clots from 
the vagina and for antiseptic precaution as well. If the 
physician has confidence in the nurse, he requests her to 
give the douche ; if not, he gives it himself The nurse 
is responsible for the aseptic condition of the douche-tube 
and douche-bag, for the correct temperature and compo- 
sition of the fluid employed, and for keeping the douche- 
bag full or at least partially filled during the entire admin- 
istration of the douche. She should warn the doctor 
before the fluid has entirely escaped, as otherwise air 
may enter the womb and a serious accident follow. 
There are various kinds of douche-tubes in use, those 
sold with the ordinary fountain-syringe being of hard 
rubber. The best tubes are of glass, made especially 
for the purpose, which can be thoroughly boiled. The 
accompanying illustration shows a tube devised by the 
writer, which is boiled before use, and which serves 
equally well for an intra-uterine douche-tube when such 
is necessary. The nurse is also responsible for the 
aseptic condition of the douche-pan or bed-pan em- 
ployed in the giving of this douche. Some physicians 
prefer to place the patient across the bed, a rubber sheet 
beneath. In giving the douche the fountain-syringe 
should not be higher than three feet above the patient. 



74 



DUTIES OF THE NURSE DURING LABOR. 



After the douche has been given, or if no douche be 
given, the nurse should thoroughly antisepticize her 
hands, and then exposing the parts should thoroughly 
sponge away blood and discharges with bichlorid solu- 




FlG. 13. — Davis's glass douche-tube. 



—Glass douche tube in jar of anti- 
septic fluid. 



tion (i :4000 to i : 2000). The doctor should order the 
strength of the solution. This should be done with 
gauze or cotton sponges. A sea-sponge should never 
be used about a puerperal patient. When the parts 



LABOR WITHOUT THE DOCTOR. 75 

have been thoroughly cleansed and dried, an antiseptic 
dressing should be applied, attached either to a binder 
or a T-bandage, as the physician may direct. 

The Binder. — The application of the binder is a 
matter which must be decided by the doctor. If there 
is danger of hemorrhage, the binder should not be 
applied. If the nurse is told to proceed with its appli- 
cation, she must first be sure that the uterus is well 
contracted, being hard and firm. To apply the bandage 
properly, it must be fastened from above downward. 
The uterus should be brought downward and forward 
against the brim of the pelvis. The purpose of the binder 
is to carr\" the abdominal viscera down against the 
womb, and, pressing the abdominal walls gently but 
firmly, to retain the uterus in position against the pelvic 
brim. If the binder be pinned fromi below upward, it 
may push the womb up into the abdominal cavity, and 
relaxation of the uterus and hemorrhage may result. 

I/abor without the Doctor. — Cases sometimes arise 
in which the nurse is left entirely alone with the patient 
at the time of labor. The physician does not reach the 
case in time, the labor is precipitate, and the nurse is 
called upon to deliver the patient. Fortunately, in these 
cases, there is no serious obstacle to the expulsion of 
the child, or birth could not occur so rapidly. Under 
these circumstances the nurse should place the patient 
upon her left side at the edge of the bed, drawing up 
the thighs and placing a pillow made into a firm roll 
between the patient's knees, thoroughly cleaning the 
hands, and placing a basin of bichlorid solution (i : 2000) 
at her side, with gauze or cotton sponges in the basin. 
The nurse should lay the right hand across the perineum 
of the patient, a gauze or cotton sponge being placed 



76 DUTIES OF THE NURSE DURTNG LABOR. 

over the anus. The hand should not completely cover 
the perineum, but should leave a half inch of tissue at 
the vagina uncovered. As the head comes down the 
nurse should gently support the perineum and pelvic 
floor, making pressure upward and backward. If the 
head comes so rapidly that it seems in danger of tearing, 
the nurse may pass her left arm between the patient's 
thighs, placing the fingers of the left hand upon the top 
of the child's head and holding the head back. The 
mother should be told to open the mouth widely, not 
to bear down, and to breathe as slowly as possible. The 
nurse must then watch her opportunity to let the head 
slip out before the mother has a hard pain. In this way 
a serious tear can usually be avoided. When the head 
has been born the nurse should pass the finger to the 
neck, to see if the cord is around the neck. If it is, 
it should be slipped over the head if possible. When the 
shoulders are born the head of the child should be raised 
up with the left hand, while the right hand protects the 
perineum. So soon as the child is born it is turned 
upon its right side. The nurse should grasp the womb 
through the abdominal wall with one hand, and with the 
other feel the pulsation of the cord. If the cord is not 
beating, it must be tied an inch from the umbilicus, and 
in a- second place just beyond, and cut between the two 
ligatures. If the child does not breathe and cry, it must 
be held with the head down and folded and unfolded 
upon itself gently, when respiration will usually become 
established. When the child breathes and cries it may 
be taken away, wrapped in a warm blanket, and placed 
upon its right side. 

The mother is then turned upon her back, and the 
nurse sits by her side holding her hand gently but firmly 



LABOR WITHOUT THE DOCTOR. 



77 



upon the uterus. She should make no effort to deHver 
the placenta until the mother has contractions of the 
uterus or unless hemorrhage begins. If the doctor does 
not come in time to deliver the placenta, and if the 
mother has pains, the nurse should assist the pains by 




a (^ Dickinson). 



pressing the womb downward and forward, and by grasp- 
ing it between the thumb and the fingers placed behind 
it, and compressing^ the womb from before backward. 
When the placenta appears at the vulva the nurse should 
grasp it and rotate it, drawing gently downward and 



78 



DUTIES OF THE NURSE DURING LABOR, 



backward, so that the membranes will twist into a cord. 
In this way all the membranes come away. The pla- 
centa must always be saved for the doctor's inspection. 
After the delivery of the placenta, the doctor still being 
absent, the nurse may give a teaspoonful of fluidextract 




Fig. i6. — Extracting the head, breech labor. 

of ergot, see that the womb is firmly contracted, and, 
if the patient does well, may apply the binder and clean 
and dress the patient as usual. 
I/abor with Breech Presentation. — The child is 



TWIN LABOR, 79 

sometimes born with the head coming last and the feet 
and breech first. These cases are dangerous to the child, 
because at the moment of birth the neck of the child 
may be compressed and the child may die. If a nurse 
were alone with such a case, when the feet and limbs of 
the child appear the mother must be turned across the 
bed, her feet resting on a couple of chairs. The nurse 
should wrap the body and limbs of the child in a warm 
towel and support the body very gently until the body 
is born. Then the body should be raised toward the 
mother's abdomen with one hand, while the other is 
placed just above the pubes, and pressure is made down- 
ward and backward. The mother should be told to close 
her mouth and bear down as strongly as she can, when 
the arms and head of the child will be born (Fig. i6). 

Twin I/abor. — If a nurse were alone with a case of 
twin labor, after the first child has been born she should 
wait, encouraging the patient and keeping the hand upon 
the uterus. Twins are rarely as large as other children, 
and there is not much difficulty in their birth unless some 
complication occurs. When the second bag of waters 
ruptures the second child is usually born easily. There 
is danger, however, that the womb will not contract 
promptly, and so the nurse must be very careful to keep 
her hand upon the uterus, and to see to it that the womb 
does not relax. When the patient begins to expel the 
placenta the nurse should assist her by compressing the 
uterus in the manner already described. There is great 
danger of post-partum bleeding in twin labor, and so the 
nurse must be especially careful to see that the womb is 
well contracted before she applies the binder. If there 
is any tendency to relaxation, two teaspoonfuls of ergot 
should be given at once, and one teaspoonful every hour 
for the next two or three hours. 



CHAPTER VI. 
THE PUERPERAL OR LYINQ=1N PERIOD. 

Duration. — The time required for the complete 
recovery of a mother from labor varies greatly. From 
six weeks to three months usually elapse before the 
patient is entirely well, and in some cases a still longer 
period. As the patient is in bed a part of this time, it 
has been termed the lying-in period, or the time of con- 
finement. Formerly it was thought that one month was 
sufficient for the services of a nurse, and so obstetric 
nurses were called monthly nurses. 

Involution. — During this time the womb and other 
portions of the genital tract are becoming smaller, until 
they are nearly in the condition in which they were 
before pregnancy occurred. This process is called 
involution. Wounds in the soft tissues during labor 
gradually heal. The abdominal muscles which were 
stretched contract and become nearly as firm as before. 
The secretion of milk is established and continues. Some 
patients lose in weight while nursing the child, while 
others gain. The majority of health}' women gain after 
childbirth. The mother is never so small as before her 
pregnancy, unless artificial means be used to compress 
her body. She is larger about the waist and about the 
chest than before. 

I/OChia and Bowels. — The lining membrane of the 
womb is shed off during the lying-in period, and with the 
discharge of other tissue from the uterus forms the lochial 



SOILED LINEN. 8 1 

discharge. This is at first bloody, then serous, and lastly 
mucous. It is altered in cases of septic infection. The 
intestinal tract of the patient has been usually distended 
with feces during pregnancy. After the bowels have 
been emptied the intestines gradually regain their normal 
size and elasticity. 

Rest. — The first absolute necessity for the mother in 
the lying-in period is rest. It is sometimes very hard to 
persuade her friends and relatives that such is the case. 
Joy over the birth of the child, curiosity to see it, and 
general excitement disturb the mother very much. It is 
the duty of the nurse, however, to see that when the 
mother has been properly cleansed and suitable dress- 
ings applied, and her bed made clean and comfortable, 
that the room should be darkened, and that the patient 
should enjoy perfect quiet, and if possible several hours 
of sleep. Although the mother rests the nurse must 
remain watchful. She must know that the patient's pulse 
is good ; that the flow of blood from the uterus is not 
excessive ; that the patient's extremities are warm ; and 
that her sleep is a healthful and restful one, and not a 
dangerous unconsciousness caused by bleeding or fatal 
syncope. If the nurse is neghgent, a mother may bleed 
to death while the nurse supposes her to be asleep. 

Soiled lyinen. — While the patient sleeps the nurse 
will have time to wash and dress the child, to place linen 
and other articles soiled during the labor in cold water to 
soak, and to make the rooms which have been used neat 
and tidy. If linen or clothing has become much blood- 
stained, it should be soaked in cold water containing 
sodium bicarbonate. If it be repeatedly rinsed, the 
blood will entirely disappear, and the clothing may then 
be washed in the usual manner. Clothing or other 



82 THE PUERPERAL OR L YING-IN PERIOD. 

articles stained with blood should never be washed in 
hot water or boiled. The heat coagulates the blood, 
making the cleansing very difficult. 

The Newborn Child. — When the mother wakes 
from the first sleep her natural desire will be to see the 
child. If she is in good condition, and the child also, 
this desire should be gratified, and the opportunity 
should be taken to put the child to the breast. This is 
done because the child's nursing will increase the con- 
tractions of the womb and stimulate the flow of milk, 
while the child may obtain fluid useful in moving the 
bo^wels. Before the child nurses, its mouth should be 
wiped out with a small square of clean linen dipped in a 
saturated solution of boric acid. The mother's nipples 
should be washed with Castile soap and warm water, and 
then with boric-acid solution before the child nurses. 
After the child nurses the nipple should be sponged and 
dried with Hnen soaked in boric-acid solution. 

It is often difficult to induce the child to take the 
nipple for the first time. If the mother takes the child 
upon her arm and turns upon her side, the breast will 
naturally fall so that the nipple will come easily into the 
child's mouth. It is usually unnecessary to do more 
than simply moisten the nipple, when the child will 
nurse eagerly. But little fluid is present in the breast 
at first, and the child after trying for a moment may 
desist because it obtained nothing. As the secretion 
of milk increases the child will increase its efforts to 
nurse. 

Cleanliness for the Mother. — It is very important 
in the lying-in period that the mother should be kept 
clean, and that she should have abundant and proper 
diet and sufficient rest. Her room should be absolutely 



MASSAGE AND POSTURE. 83. 

neat, the bed-linen changed as often as necessary, the 
antiseptic dressings frequently renewed, and in every 
particular the patient and her surroundings must be 
models of neatness. If the nurse manages well, she will 
do her work at regular times, conforming to the habits 
of the patient and the household, and thus the care of 
the patient will go on smoothly. 

Each puerperal patient requires at least one thorough 
soap-and-water sponge -bath daily. This is best given in 
the morning, usually about an hour after breakfast. The 
use of highly scented soaps is objectionable, and a wash- 
cloth is preferable to a sponge. Water or wash-cloth used 
in general bath must not be used for vulvar cleansing. 
Careful attention must also be given to the patient's hair 
that it does not become uncomfortably matted or tangled 
while she is in bed. If it is grateful to the patient, she 
may also have light rubbing with alcohol in the evening, 
about an hour before the time when she goes to sleep. 

Massage and Posture. — During the latter portion 
of the puerperal period massage is a most important 
method of advancing the patient's recovery. This 
should be given very gently at first, the back and limbs 
only being treated. Later on, the entire body, including 
the abdomen, may be subjected to massage with great 
benefit. In caring for the patient's skin while she is in 
bed, it must be remembered that some persons cannot lie 
upon rubber sheeting without considerable suffering, and 
sometimes with unpleasant eruptions. When this is the 
case the rubber draw-sheet may be removed, and pads 
made of cheesecloth and filled with borated or sterile 
cotton may be used instead. If attention be paid to the 
proper application of vulvar dressings, these pads will 
usually be found sufficient. The posture of the lying-in 
patient is of importance. Immediately after delivery she 



84 THE PUERPERAL OR L YING-IN PERIOD. 

should He quietly upon the back, and remain so until she 
has perfectly reacted from labor and until all danger of 
hemorrhage or relaxation of the uterus is passed. After 
this it is injurious for the patient to lie constantly upon 
the back, because this posture favors tipping backward 
of the womb. So soon as the mother can move about 
comfortably in bed she should turn on either side ; or, 
if she desires, she may lie upon the abdomen. The 
shoulders are not usually raised from the bed for several 
days after confinement, but the patient may be gradually 
propped up in bed, with the doctor's permission, until 
she assumes very nearly the sitting posture. 

I/ight and Air. — The day is fortunately past when it 
was thought necessary to keep the room of a puerperal 
patient dark and close. So long as the patient is fatigued 
she naturally does not desire a bright light; but when 
she is not asleep the light in the room should be that 
best adapted to her comfort. Excepting in hot weather, 
abundant sunshine is an excellent thing for such a room, 
and should be admitted most freely. The ventilation of 
the lying-in room should be as perfect as possible. This 
may be accomplished by raising the lower sash of one or 
tv/o windows and placing beneath it a strip of board con- 
taining a ventilator or without it. An air space is thus 
formed between the upper and lower sash which prevents 
a draft. An open fireplace is also of the greatest assistance 
in securing good ventilation. Screens such as are used 
in dining-rooms and other apartments may be utilized to 
avoid drafts. 

Mother and Child. — The mother very naturally 
desires to have the child near her. Its presence, however, 
in her room is most undesirable. Many newborn children 
are restless at night for the first week or ten days after 



BOWEL MOVEMENTS. 85 

birth, and if they be in the room with the mother she 
must* necessarily be disturbed and lose important rest. 
The child is often put in the room with the nurse, this 
arrangement enabling her to care for the child without 
disturbing the mother. The child's room may be near 
the mother's and adjacent ; but there should be a door 
between them sufficiently heavy to prevent the mother 
from hearing the child's cries. Where it is impossible to 
keep the child in any other than the mother's room, the 
best must be made of such an arrangement, but it will 
result in much fatigue for the mother. 

Warmth. — While the lying-in room should be well 
ventilated, it should also be comfortably warm. Imme- 
diately after labor the patient experiences a considerable 
reaction and often complains of a chilly sensation. The 
best form of heat is an open wood fire. Next to this is 
an open stove burning hard coal ; while worst of all is a 
register from a furnace, which brings heated and foul air 
from the cellar of the house. 

Bowel Movements. — Within the first forty-eight 
hours after labor the mother's bowels should be thoroughly 
but gently moved. Almost no pregnant woman escapes 
constipation, and while the intestine may seem to be 
empty at the time of labor such is rarely the case. The 
medicine prescribed by the physician is usually followed 
by an order for an enema, the composition of which 
should be directed by the physician himself If this be 
left to the nurse, an enema of castor oil, soapsuds, the 
yolk of a raw ^%'g, and turpentine is usually found suffi- 
cient. In cases in which the breasts are very full it may 
be desirable to produce a very free evacuation, and then 
an injection of Epsom salt, glycerin, turpentine, and soap- 
suds may be employed. After the bowels have been 



86 THE PUERPERAL OR L YING-IN PERIOD. 

thoroughly evacuated they must be moved regularly by 
the simplest remedies which will act. While the lower 
bowel can be cleansed by enemas, the upper portion of 
the intestinal tract is not much affected in this manner. 

Diet. — The diet of the mother after labor should be 
liquid. An abundance of water must also be taken. The 
use of liquids is necessary for the formation of milk, to 
stimulate the action of the kidneys and intestine, and to 
appease the mother's natural feeling of thirst. Water 
and milk are the best beverages ; the Hghtest forms of 
cocoa are acceptable to some, but tea and coffee should 
be used in small quantities only. Some think that coffee 
lessens the secretion of milk and that tea increases it. 
There is no positive evidence that either belief is correct. 
Liquid food may be given every three hours and once 
during the night. When the bowels have moved the 
patient usually has a better appetite and craves solid food. 

Very few patients while in bed need much meat or can 
digest it. The diet for such cases is that usually known 
as hght diet in hospitals. It comprises soft eggs, custard, 
junket, milk-toast, light puddings, broths, soups, purees, 
calve's-foot jelly, partially melted ice-cream, toast in all 
forms, sponge-cake, charlotte russe, all vegetables in 
season, non-acid fruits, raw if perfectly ripe, and, if not, 
cooked, baked apples being of especial value if not too 
sour. At the end of the first week of the puerperal 
period the patient may add to this diet once daily the 
white meat of chicken or turkey, squab, sweetbread, 
lamb chops, oysters, and fish, excluding other shell-fish. 
When she begins to be up and about her room beef, 
bacon, and potatoes may be added. Fried dishes, pickles, 
nuts, candies, cheese, rich sauces, pastry, highly spiced 
food, and alcoholic drinks should be excluded at all times. 



ASEPSIS AXD DRAINAGE. 8y 

It is customary in many cases to order malt in the 
form of an extract or a mild liquor for puerperal women. 
This is done to increase the secretion of milk and to build 
up the patient's strength. Malt liquors are not needed 
by nursing women, while it is easy to push the administra- 
tion of malt too far, thus overtaxing the digestive organs 
and bringing about a very unfortunate condition. If 
malt is employed, the thinner, lighter extracts should be 
chosen, and it should be taken with food, a wine-glassful 
at a dose three times daily. A puerperal patient needs 
plenty of the most nutritious food, but it must be remem- 
bered that any but simple food affects injuriously the 
milk, and will interfere greatly wuth the child's comfort 
and her own as well. Acid fruits eaten by the mother 
frequently cause indigestion in nursing children, and rich 
and indigestible foods are well known to produce such a 
result. 

Asepsis and Drainage. — The puerperal woman is 
a surgical patient. If a nurse is caring for a case of 
abdominal section, the wound in the abdominal wall is 
kept covered by an antiseptic dressing, which is renewed, 
if necessary, with the greatest care. It is much easier 
to keep a case of abdominal section in an aseptic condi- 
tion than a puerperal patient. The wounds in the genital 
tract after labor cannot be closed by the direct application 
of a dressing. These wounds must discharge, because 
from the uterus must escape the cells which formed the 
uterine Hning during pregnancy. The uterus must drain ; 
and if it does not, then absorption of lochia will follow 
and sapremia result. Hence the puerperal patient must 
be treated surgically with proper precaution. 

Fortunately, the provisions of Nature for the drainage 
of the birth-canal are usually sufficient, and if nothing 



88 THE PUERPERAL OR LYING-IN PERIOD. 

unclean comes in contact with the patient she remains in 
an aseptic condition. There may be within her body the 
results of inflammation before this labor, but that cannot 
be helped by the nurse, and she is not responsible for them. 
When it is necessary to change the vulvar dressings the 
nurse should scrub her hands with soap and hot water, 
then with hot water, and then with a solution of mercuric 
chlorid (i : 2000). There should be ready a basin of 
bichlorid solution (i : 4000 or i : 2000), as the physician 
may direct. In this should lie pieces of sterile cotton 
or of sterile gauze. The clean dressing to be applied 
should be in convenient reach. The nurse should place 
beneath the patient a douche-pan or bed-pan, or if she 
cannot be placed upon such a vessel a mass of cotton 
or of gauze should be placed beneath the vulva. Some 
nurses prefer to irrigate the external parts with a stream 
of antiseptic fluid running from a fountain-syringe or 
small pitcher. Others use simply gauze or cotton 
sponges. To cleanse the parts, the nurse, with antiseptic 
hands, irrigates or sponges the external parts thoroughly. 
Then, separating the labia with the fingers of the left 
hand, she directs a stream of antiseptic fluid from a 
fountain-syringe or small pitcher upon the external parts 
and the entrance to the vagina, washing these parts per- 
fectly clean. If a syringe or small pitcher is not used, 
she should saturate a handful of gauze or cotton with 
the antiseptic fluid, and, holding the labia apart with the 
left hand, the right should be placed above the parts, 
the gauze or cotton squeezed, and the fluid allowed to 
run over the parts. No finger or instrument should be 
inserted within the vagina without the doctor's precise 
orders. When the parts are thoroughly cleansed the 
external parts may be gently dried with gauze or cotton 
sponges. The fresh dressing is then applied. In some 



THE BREASTS. 89 

cases physicians order that in addition to the usual 
cleansing an antiseptic powder of some sort be dusted 
upon abrasions and small lacerations at the entrance to 
the birth-canal. This, of course, must not be done with- 
out the doctor's orders. Soiled dressings when removed 
should be wrapped in waste paper and burned. They 
should not be placed in a furnace, as the fumes may pass 
through the flues of the house. They should be burned 
in a range, a stove, or fireplace at the most convenient 
time. Very often during the night the nurse can succeed 
in burning the day's dressings in the kitchen range. The 
nurse should watch carefully for evidences of a foul dis- 
charge on the napkins, from inflammation or irritation 
caused by the dressings or antiseptic solutions employed. 
Dressings should be changed and the patient cleansed 
whenever the dressing is stained through, whenever the 
bladder or bowel is emptied, and as often as the physi- 
cian may direct. 

The Breasts. — As the nipples of the mother may 
become wounded, it is necessary to protect them with 
aseptic dressings. The test of the value of a breast- 
binder is the comfort which it gives the patient. It 
should hold the breasts gently but firmly, raising them 
and drawing them inward toward the middle line. The 
nipples should be covered by the softest possible aseptic 
materials ; sterile gauze usually answers the purpose very 
well. After the baby nurses the nipples should be thor- 
oughly but gently cleansed with sterile water or with 
some antiseptic solution which the doctor will order. 
Many physicians employ a saturated solution of boric 
acid. When the nipples are tender and a crack or fissure 
is feared, an antiseptic ointment may also be employed 



90 THE PUERPERAL OR LYING-IN PERIOD. 

to advantage. Other physicians prefer a simple sterile 
fat, as sterile olive oil or cocoa-butter. 

• Catheter. — It is often necessary to catheterize a puer- 
peral patient, and this requires the strictest antiseptic 
precautions. The catheter must be boiled, the hands of 
the nurse made aseptic, and the patient's parts gently 
but thoroughly cleaned with antiseptic solutions. 

Asepsis. — No instrument or utensil or appliance 
which is not surgically clean should be used about the 
puerperal patient. It may seem unnecessary to be so 
exact in small things regarding asepsis during the lying- 
in period, but patients unfortunately sometimes suffer 
from infection of the breasts and nipples, or from infec- 
tion of slight wounds in the genital tract through the 
carelessness or inefficiency of nurses. Every precaution 
must be taken in emptying the bowels by enemas that 
the perineum may not become soiled with fecal matter, 
and that wounds or lacerations do not become infected. 

While it is difficult to prove positively that a patient 
may become septic from septic air, still cases are on 
record which seem to show that air coming from septic 
material may poison a lying-in woman. An example of 
this is as follows : A nurse in a lying-in hospital placed 
soiled dressings in a furnace in which there was no fire. 
The air from this furnace passed through a register at the 
bedside of a patient. This patient became septic. The 
next patient placed in this bed also became septic. When 
the furnace was cleaned and the dressings removed 
patients placed in this bed did not become septic. There 
should be no communication for this reason between the 
lying-in room and any sewer, drain, or cesspool. Fortu- 
nately, antiseptic agents are not all of them possessed of 
unpleasant odor, and hence a patient may be treated with 



VISITORS. 9 1 

every antiseptic precaution without disagreeable odor. 
The placenta should be destroyed by fire, or, if this is 
not possible, it should be buried several feet below the 
surface of the ground. It should never be placed in a 
water-closet or drain-pipe. 

Visitors. — The regulation of visits made by out- 
siders to the patient is often a matter of difficulty. There 
are many reasons why but few people should call upon 
such a case. The patient's exhausted condition im- 
mediately after labor forbids it. The child is more inter- 
esting to her than any visitor, and hence she needs little 
if any other society, while each visitor may be a source 
of danger through the conveyance of some contagion or 
infection. Unfortunately, it is not often possible to select 
visitors for their beneficial character upon the patient. 
Still, only those persons known to be in good health and 
free from contagion, and cheerful and encouraging by 
nature, should ever be admitted. It is usually best to 
limit visitors to the patient's nearest friends until she is 
able to go out. Importunate persons can often be ap- 
peased if the baby is shown to them. This satisfies their 
curiosity, and gives them an opportunity of comparing 
the child with their own and others of their acquaintance. 

Only those who have had experience realize the sensi- 
tiveness of puerperal women. They are easily excited, 
easily alarmed, and very readily frightened. Hence every 
precaution must be taken to keep the mother as happy 
and as undisturbed as possible. The results of excite- 
ment and alarm are seen in high fever, disordered milk, 
sickness of the child, and sometimes a very serious or 
fatal syncope in the mother. Knowing this, the nurse 
must guard her patient accordingly. This period is a 
restful and happy one for the mother, and the nurse has 



92 THE PUERPERAL OR LYING-IN PERIOD. 

it in her power to secure this desired result, but by her 
lack of tact and good management she may very much 
retard the recovery. If the nurse meets the family and 
visitors with firmness, but with courtesy and tact, she 
will rarely fail in securing the desired result. 

Getting" Up. — The question of the mother's getting 
up from confinement is one which is constantly brought 
to the attention of the nurse as well as of the doctor, and 
her friends. Women usually expect to be up and about 
on the tenth day after the birth of the child when the 
confinement occurs among the poorer classes. It is evi- 
dent that there is no fixed limit for the lying-in period, 
but that each patient must get up in proportion to her 
recovery and to her strength. It is for the doctor alone 
to decide when the patient shall leave her bed. 

The first beginnings of getting up are when the patient 
sits up in bed to eat her meals. Then she leaves her bed 
to use a commode, and then reclines upon a couch for 
the greater part of the day, finally sitting and walking 
about her room. So long as there is a free reddish dis- 
charge the patient should not be upon her feet. Very 
often the discharge becomes more abundant and red in 
color so soon as the patient gets up, and when this happens 
she must be more than usually cautious in assuming the 
upright posture. The average patient can leave her bed 
to use a commode at the end of ten days or two weeks, 
can be partially dressed and lying upon a couch during 
the third week, and up and about her room in the fourth 
week. Her going out of doors must depend upon the 
weather, upon her general strength, and upon the means 
at her disposal. She should go out at first in a carriage 
if this is possible, and begin to walk and take active 
exercise very gradually. 



THE MOTHER'S FIGURE. 93 

So soon as the patient gets about it is necessary that 
she should go up and down stairs. This is an especially 
trying and difficult exertion for a woman immediatel}; 
after labor. She may be able to go down with the assist- 
ance of the baluster, but when she returns she should be 
helped by some one who stands beside her with the arm 
about her waist, lifting her upon each step, or, standing 
directly behind her, lifts her by placing the hands upon 
the hips. 

Physician^ S i^xamination. — Before the patient is 
declared to be well and able to go about most physicians 
make a thorough internal examination to ascertain that 
no malposition of the uterus is present. To do this the 
physician requires hot water, soap, an antiseptic solution, 
and some lubricating material for the examining finger. 
The patient is placed upon her back at the edge of a bed, 
with her feet on chairs, and a bimanual examination is 
made. 

The Mother's Figure. — Patients are often anxious 
about the getting back of the figure after confinement. 
By this many expect to be as small as they were before 
the birth of the child. It is often noticeable that patients 
who have especially bad figures seem very anxious that 
the figure be kept in its original proportions. Nurses are 
often asked if they bandage patients ; and patients ask 
regarding the nurse, not so much whether she is clean, 
aseptic, and intelligent, as whether she is good at getting 
back the figure. As we have remarked, it is impossible 
for a patient to be as small after the birth of the child as 
she was before ; and if her figure is of more importance 
than the child, then the birth of the child was certainly a 
calamity. If she makes a good recovery, however, the 
abdominal walls will be firm and elastic, the patient will 



94 THE PUERPERAL OR LYING-IN PERIOD. 

be able to stand erect, and to walk and exercise as she 
formerly did, and she will have quite as good a figure as 
she ever had. Some patients who were very thin and 
ill-nourished before the birth of the child become slightly 
stouter and much improved in looks after the child is 
born. The nurse should assure her patient that she will 
take every precaution to see that the patient makes a 
good recovery, and that if this occurs the patient will 
have a comfortable figure. The term " figure " is used by 
many to mean the human body as constricted by a corset. 
This is a deformity of very common occurrence, and is 
preferred by "many to the natural shape of the body. If 
a woman after confinement desires a corset figure, she 
can obtain it by putting corsets on early, by lacing them 
tightly, and fastening her clothing around her waist so 
as to assist the corset in dragging and forcing down the 
organs in the abdomen. It is not the part of a trained 
nurse, however, to assist in producing any such defor- 
mity. If a patient does not desire to be deformed in this 
way, if she makes a good recovery from labor, she will 
be in better health and have a stronger and more grace- 
ful body if she will avoid the use of corsets, suspending 
the clothing from the shoulders and using styles of 
clothing which avoid constriction of the waist. 



CHAPTER VII. 
THE NEWBORN CHILD AND ITS CARE. 

Physiology of the Infant. — The child comes into 
the world with only its physical nature developed, and 
with certain very definite needs and indications for its 
care. Its digestive apparatus is in a delicate condition ; its 
stomach is but little dilated, and hence it requires easily 
digestible food in small quantities and at frequent inter- 
vals. The organs of digestion and excretion are not in 
a condition to perform their functions fully, and the same 
is true of the lungs. Hence respiration, digestion, and 
excretion become gradually established. Several days 
elapse before the lungs are fully expanded, while from 
several days to a week often pass before the kidneys and 
bowels act freely. The nervous system is in a delicate 
condition, capable of reacting to very gentle stimulation, 
and likely to be severely impressed by shock. The child 
appreciates heat and cold keenly, and hence gives evi- 
dence of its comfort or discomfort according to the tem- 
perature of its body. 

The discharges from the intestines and kidneys are 
especially interesting in young children. The first bowel 
movements are dark, resembling tar or burnt molasses, 
and gradually give place to the bright-yellow movements 
which are seen in health. The urine first discharged 
stains the diaper a reddish pink, sometimes a brick color, 
and this stain gradually gives place to a colorless state 
of the urine or to a faintly yellow tinge. The gradual 

95 



96 THE NEWBORN CHILD AND ITS CARE. 

change of the color of the discharges from the bowels 
and kidneys is an index of the activity of these organs 
and of the prompt establishment of the child's digestion. 
If the urine does not grow clear and the bowel move- 
ments remain black and thick, the child's digestion 
becomes established with considerable difficulty. During 
the first week or ten days the child is often jaundiced. 
This comes from the absorption of blood-pigment, and not 
because of disease of the liver. In healthy children it 
disappears in a short time. 

At birth the stump of the umbilical cord is attached 
at the child's umbilicus and surrounded by an elevated 
rim of integument. The cord gradually withers, becomes 
black and shrivelled, and finally comes away, leaving a 
small granulating surface, which retracts and is almost 
covered by the skin. 

The healthy newborn child sucks vigorously. It cries 
actively, moves its limbs freely, and has considerable 
vigor in the grasp of its hands and feet. Although the 
grasp of the hands is much the better developed, still it 
tries to hold objects with the toes, and if the object be 
small enough it may partially succeed. 

Its First Food. — The craving for food which the 
child soon manifests is accompanied by considerable 
thirst. This is a wise provision of nature, as a free 
amount of fluid is necessary to flush the kidneys and 
establish the secretion of urine. Immediately after birth 
the mother's breasts rarely contain milk of an especially 
nutritious character. In most cases the fluid is thin, 
comprised of water, saline material, and young cells from 
the milk-ducts of the breast. This is a laxative much 
needed by the child. It is called colostrum, and gradually 
gives way to the fully formed milk. If the child were to 



MOTHER'S MILK. 9/ 

depend entirely upon the mother's breast for the first few 
days of its Hfe, it would receive but httle nourishment. 
It comes into the world, however, with a considerable 
number of red blood-cells and other nourishing cells in 
various portions of the body, so that it is not in imme- 
diate need of food. If abundant water be given, so 
that the circulation of the child can have fluid and the 
glands of its body begin to act, the child will do well. It 
should not be fed by artificial means unless the coming 
of the mother's milk is delayed beyond the usual period. 
For forty-eight hours the child will do well upon colos- 
trum and water if it be a strong and vigorous child. If 
it be prematurely born and weak, it may require addi- 
tional nourishment or stimulus. 

Mother's Milk. — The mother's milk forms gradually, 
usually by the end of the first three days after birth. In 
some cases it comes into the breasts so suddenly that the 
sensation is that of a rushing fluid. 

The secretion of milk is greatly promoted by the stimu- 
lus of the child's nursing, especially if this be done at 
regular intervals. The attending physician should pre- 
scribe exactly the periods for nursing, and absolute regu- 
larity should be observed in carrying out his directions. 
At first the child usually nurses once in four hours, and 
once or twice during the night, for the first forty-eight 
hours. Then it nurses every three hours from 6 a. m. to 
10 p. M., and once during the night; and when the secre- 
tion of milk is fully established, every two or three hours 
between six o'clock in the morning and ten o'clock in the 
evening, and once during the night. It is often difficult 
to keep a child awake during the day to nurse, although 
it will remain awake at night and nurse freely for a con- 
siderable time. Still, the child should be roused at regular 
7 



98 THE NEWBORN CHILD AND ITS CARE. 

intervals, and in the course of a week or ten days it will 
form regular habits. 

The Child^s Stomacli. — The capacity of the child's 
stomach gradually increases with the amount of food 
available. The natural measure of the infant's meal is 
the contents of one breast, and in the course of ten days 
or two weeks the secretion of milk will adapt itself to the 
appetite of the child, and sufficient, but no more, will be 
formed. The child should nurse the breasts in alterna- 
tion, and before and after nursing the nipples should be 
cleansed with boric-acid solution or sterile water. If there 
is danger that cracks or fissures will form, the nipple 
should be anointed after each nursing with an antiseptic 
ointment or with sterile olive oil. 

Nursing". — In some cases the child is slow in grasp- 
ing the nipple in beginning to nurse, and the nipple must 
be moistened with water, or possibly with milk, before 
the child will grasp it actually. A solution of sugar is 
sometimes used to moisten the nipple, although this can- 
not be commended. In some cases the child nurses so 
greedily as to swallow a large quantity of milk suddenly, 
thus causing regurgitation and colic. The mother can 
do something to prevent this, if she will lay her hand 
across the under surface of the breast, grasping the 
nipple between the longest and the next finger and com- 
pressing the nipple as the child nurses. In this way the 
flow of milk is hindered and the child is obliged to nurse 
more slowly. In some cases the breast is so distended 
with milk that the child cannot cause the milk to flow 
freely. Here the tension must be lessened with the 
breast-pump by drawing two or three drams of milk, 
when the child will be able to nurse. In some patients 
the first milk found in the breast is exceedingly rich in 



WATER. 99 

fat and does not agree well with the child. The use of 
the breast-pump to remove this milk before the child 
nurses is usually all that is sufficient. 

The taking of food through nursing by an infant 
should be done with care and regularity. It is a great 
mistake for the mother to allow the child to drop asleep 
with the nipple in its mouth, as the constant sucking of 
the child upon the nipple has a tendency to soften it and 
to cause it to crack easily and fissure or become sore. 



Fig. i8. — Breast-pump. 

The time occupied by a healthy infant in emptying a 
normal breast is from fifteen to twenty minutes. When 
the child drops asleep and cannot be roused to nurse, 
then the act of nursing should cease. 

Water. — In addition to the milk which the child 
obtains water should be given regularly by the nurse 
or caretaker. It is better to have water which has been 
boiled and cooled than to trust to water which has not 
been made sterile. An infant will usually take it from 
a teaspoon or bottle ; but if difficulty is experienced in 
this, the water may be dropped into the mouth from a 
medicine-dropper. Until the secretion oi urine is abundant 
and the urine is not highly colored, the infant should have 
water every four hours unless asleep at night. The tern- 



lOO THE NEWBORN CHILD AND ITS CARE. 

perature of the water should be neither high nor low, 
but pleasantly cool. 

Warmth for the Child. — The temperature of the 
newborn child is considerably above that of the healthy 
adult, and care must be taken that the infant does not 
become chilled. At the same time too great heat is most 
depressing and injurious. The most agreeable warmth 
for the child is that of an open wood-fire or of an open 
coal-fire, which gives a circulation of air. It is noticeable 
that infants that are not sufficiently warm almost imme- 
diately cry and fret, so that if a child is not hungiy, and 
if its diaper does not require changing, we may suspect 
either heat or cold to be the source of its annoyance. 

Sleep. — The newborn child spends a large part of 
its time in sleep, and this should not be disturbed except 
for very good reasons. As the child at first has no con- 
sciousness of the external world, it is useless to disturb it 
with the idea that it is an intelligent creature which can 
give response. It may be with the mother sufficiently 
often to interest her, but otherwise it should be allowed 
to sleep and rest in quiet. 

Clothing. — Infants' clothing should be as simple and 
as comfortable as possible. The number of garments 
actually needed is very small indeed. A thin, soft woollen 
undershirt, an abdominal band or binder, a pair of socks, 
a flannel slip which combines a jacket and skirt, and a 
diaper are the only articles of clothing necessary. For 
neatness, a white slip may be worn over the flannel one. 
Several small flannel wraps of different weights and sizes 
should be in readiness for use when it is necessary to 
carry the child from its crib to the mother or from one 
room to another. When the child is dressed its two slips 
may be put on together by drawing the sleeves one 



BATHING. lOI 

within the other. When it is old enough to go out a cap 
and heavier wrap will be necessary. The skirts of the 
infant's clothing should come but a short distance below 
the feet. All the clothing should be loose about the 
body, permitting the child to move freely. If the slips 
are too long, the movements of the feet are restricted, and 
the child does not develop so rapidly nor so perfectly. 

Bathing. — Most infants are given a warm soap-and- 
water bath very shortly after their birth. This is done to 
remove the caseous material which very often smears the 
skin. If the child be rubbed with sterile olive oil before 
it is bathed, the caseous material will be removed more 
easily. Whether the bath be continued or not after the first 
cleansing depends upon the constitution and vigor of the 
child and the wish or belief of the attending physician. 
The first bath should be at a temperature of 1 00° F., 
with Castile soapsuds, and should be given in a warm 
room at a fireside if the weather be cold. Care should 
be taken to bathe the head and body with two different 
wash-cloths or sponges. There should be no hesitation 
in using soap freely upon the scalp, as sebaceous matter 
will become crusted upon the head unless this be thor- 
oughly done. Many mothers and nurses prefer the use 
of powder after the child has been bathed. This is 
placed in the flexures of the limbs, in the armpits, and 
about the genital organs, to prevent the child from chaf- 
ing by the folds in the flesh or by its diaper or clothing. 
In other cases a simple ointment is used or sterile olive 
oil is employed. If the child be bathed regularly, the 
bath is usually given in the morning, and the nurse must 
take care that the child is not exposed to chill. If pos- 
sible, she should sit before an open fire, and should be 
surrounded by a screen to prevent draft. A bathing- 



102 THE NEWBORN CHILD AND ITS CARE. 

apron of flannel is especially desirable, and this should 
be double or having two layers. If the child is active 
and the nurse's clothing is likely to be soiled, she may 
put on first a rubber apron, and over this a double bath- 
ing-apron which is of flannel, soft and thick. The child 
lies upon the under thickness of flannel while it is rubbed 
and dried. Care must be taken that separate wash-cloths 
are used for the head and for the remainder of the body, 
in order to prevent the possibility of contaminating the 
eyes. Two wash-bowls should also be employed, or else 
the head and face washed before the remainder of the 
body. The eyes should never be rubbed with a wash- 
cloth, but should be cleansed by dropping sterile water 
in them from a medicine-dropper which is perfectly clean. 
In bathing the child the stump of the umbihcal cord and 
umbilicus must not be moistened. This should be 
co\'ered by sterile gauze or cotton during the bath. 
Bathing should be followed by gentle massage over the 
entire body. If the child is puny and ill nourished, mas- 
sage may be combined with the inunction of oil by, hav- 
ing the nurse anoint her hands with sterile oHve oil or some 
other suggested by the physician in charge. Physicians 
differ regarding the use of the bath-tub. Some prefer 
that the child should not be put in the tub until the com- 
ing of warm weather if the child has been born during 
the winter. Others allow the child to be placed in the 
water so soon as the umbilicus is healed. In some cases 
the physician does not allow the child to be placed in the 
tub during its infantile life. Whatever may be done in 
this matter must be definitely prescribed by the physician 
in charge. 

If the weather be excessively warm or the child be 
depressed from any cause and restless, it is often advan- 



DRESSI.VG THE UMBILICUS. IO3 

tageous to give it a sponge or rub with alcohol just 
before it is put to sleep at night. A quart of water at a 
temperature of 100° F., to which are added two table- 
spoonfuls of alcohol, makes a refreshing bath-mixture 
when the child is fretful and has a tendency to sHght 
fever. Infants are occasionally ordered medicated baths 
for diseases of the skin or for a tendency to chafe. 
In bathing infants none but the purest soap should 
be used, and preferably without scent. Soft knitted 
wash-cloths, which should be boiled at least once 
weekly, may be employed. The child's body should 
never be entirely exposed during the colder months, but 
remain wholly or partially covered by the flannel bath- 
ing-apron. Considerable care and skill are necessary to 
give the child the greatest comfort with the least expos- 
ure and risk. 

Massage. — After the morning bath, and before the 
infant is dressed, it may be given massage from ten to 
fifteen minutes. The nurse's hands should be thoroughly 
washed with warm water and soap, and then lubricated 
with olive oil or with some other pure fat. Physicians 
sometimes order inunctions after the morning bath. 

Dressing- the Umbilicus.— Care must be taken that 
septic infection of the infant does not occur through the 
umbilicus, the eyes, or the mouth. The stump of the 
cord should be dressed with some sterile absorbent 
material which can readily be kept in place by the ab- 
dominal bandage. Many employ sterile powders, using 
baked starch, or saHcylic powder (seven parts) and 
baked starch (one part), or talcum powder, or pow- 
dered boric acid, or powdered zinc oxid. Others use 
no powder, but employ sterile or antiseptic gauze. Occa- 
sionally the cord is enveloped in sterile absorbent cotton. 



I04 THE NEWBORN CHILD AND ITS CARE, 

Whatever the doctor orders in this matter must be care- 
fully carried out lest the child be exposed to danger from 
this source. To dress the umbilicus the nurse should 
wash her hands thoroughly and brush them in a solution 
of mercuric chlorid (i : 2000). The soiled dressing 
should be removed very gently, avoiding traction upon 
the cord which might cause it to bleed. When the 
dressing has been unfolded and removed the umbilicus 
and cord should be very gently sponged with aseptic 
cotton and such solution as the doctor may order. The 
sterile dressing then prescribed should be applied, the 
stump of the cord being brought up toward the infant's 
right side and held in place by a smooth bandage of 
soft flannel pinned about the abdomen. 

The Mouth. — The mouth of the infant must be kept 
aseptic by cleansing the mother's nipples before and 
after nursing, and by cleansing the child's mouth should 
grayish-white patches appear upon the tongue and the 
sides of the mouth. The nurse must remember never 
to put a dirty finger or article into the child's mouth, 
as otherwise infection may arise. Should it be necessary 
to cleanse the mouth, the softest linen should then be 
employed which has been repeatedly boiled and has been 
dipped in sterile water or boric-acid solution. 

The Byes. — The eyes should be protected from infec- 
tion by thorough cleansing at the time of birth by flush- 
ing them with boric-acid solution or sterile water, as 
the doctor may order. After its birth the eyes may 
also be flushed with sterile water by the use of the 
medicine-dropper, and any evidence of the formation of 
matter, sticking together of the lids, or redness about 
the eyes should be at once reported to the physician 
in charp;e. 



• DISCHARGES FROM BLADDER AND BOWELS. I05 

Habits and Nerves. — Although the newborn infant 
does not appreciate many of the sensations which adults 
have, it begins very quickly to form habits and to mani- 
fest a nervous, irritable, or quiet disposition. Very much 
of this depends upon the care of the nurse and the regu- 
larity with which she performs her duties. The child's 
habits are begun from the first day of its life. If the 
nurse is methodical, patient, and kindly, by the end of 
a w^eek or ten days the child will form regular habits 
of eating, of sleeping, and of other functions of the body 
which are the basis of good health and physical happi- 
ness. When a child cries and frets it should be ascer- 
tained whether it is hungry, whether the diaper requires 
changing, whether the child is too warm or too cold, 
or whether something about the clothing is irritating it„ 
If none of these causes is present, then the child will 
usually cease its crying if no attention is paid to it. 
Within a very few days after its birth, however, the infant 
learns that it can be taken up and obtain what it wants 
by making a disturbance and annoyance, and unless this 
is proved to be incorrect the child will soon have its 
parents and the nurse at its mercy. While children 
should never be neglected, and while the mother and 
the child should have the pleasure of being together as 
much as is consistent with the health of both, still disci- 
pline should begin at the same time that the care of the 
child first commences. 

The First Discharges from the Bladder and 
Bowels. — Within tw^enty-four hours after birth, the in- 
fant should pass urine and meconium. The latter resem- 
bles burnt molasses, and gradually gives place to yellow 
feces. The first urine is brick red and scanty. Should 
these discharges be absent, the physician should be in- 
formed. 



CHAPTER VIII. 
THE ACCIDENTS OF PREGNANCY. 

The pregnant woman is exposed to very grave dangers 
through convulsions, syncope, and hemorrhage, which 
may happen from several sources. We shall discuss 
first that which is most common, namely, abortion. 

By abortion is meant the expulsion of the ovum 
before it has grown to the stage of viability; that is, 




Fig. 19.— Ovum embedded in blood-clot (Ahlfeld). 

practically before seven months. The symptoms of abor- 
tion are pain and hemorrhage. Bleeding may be so 
severe as to weaken the mother greatly, while if a part 
of the ovum be retained and decomposes she may suffer 

106 



ABORTION. to; 

from septic infection. It is especially important in cases 
of abortion that the patient be guarded from excessive 
bleeding, and that she be protected from septic infection. 

Rest. — The duties of a nurse consist in putting the 
patient at absolute rest in bed, not allowing her to 
assume the sitting posture for any purpose whatever, 
in removing all disturbing influences from her, in keep- 
ing her absolutely clean and causing her to wear sterile 
vulvar dressings, and in saving for inspection all blood- 
clots or pieces of embryo. The physician will often 
prescribe sedative medicines to control the pain and to 
prevent the expulsion of the ovum. Opium is often 
used, and the nurse must watch for the characteristic 
effects of this drug. > 

Asepsis. — The vulvar dressings should be sterilized by 
baking or boiling, and the external parts should be thor- 
oughly washed with soap and water, irrigated thoroughly, 
and then washed with bichlorid solution of such strength 
as the doctor may order, or with some other antiseptic 
solution. The hair on the external genital organs should 
be shaved or cut close. The nurse's hands should be 
made aseptic before the dressings are changed. Blood- 
clots and debris may be placed in cold water in a white 
vessel, when they can be examined most readily. The 
diet of the patient is usually liquid or light. It is often 
necessary to move the bowels by enemas. 

It may be necessary to apply local treatment in cases 
of abortion. The nurse must have in readiness an abun- 
dance of hot water, antiseptic solutions, clean linen, and 
in some cases an anesthetic must be given. If the patient 
is to be catheterized, the catheter must be boiled before it 
is used, and the nurse's hands and the patient's external 
parts should be made thoroughly aseptic. 

Consequences of Abortion. — Nurses must remember to 



I08 THE ACCIDENTS OF PREGNANCY. 

warn patients that an abortion is quite as serious as birth 
at full term, and that recovery occurs more rapidly from 
a full-term labor than from an abortion. If a patient 
neglects the instructions of her physician, and does not 
make a good recovery after abortion, she is exposed to 
chronic inflammation of the womb or some displacement 
which may make her an invalid for many years. 

Bleeding. — If a nurse were alone with a patient who 
was having an abortion, and bleeding became so severe 
as to threaten the patient's safety before the doctor could 
arrive, the nurse would be justified in lowering the pa- 
tient's head and in giving a vaginal injection of sterile 
water at a temperature of 115° to 120° F. Stimulants 
may be given in small doses only. 

Bleeding may occur within the womb during the later 
months of pregnancy from injur>^ or separation of the 
placenta. But little blood may escape. Bleeding may 
also occur when the placenta is at or near the mouth 
of the womb and in a dangerous and unnatural* loca- 
tion. In such a case there would be a free flow of 
blood from the vagina. The question of diagnosis does 
not rest with the nurse ; but she must remember that 
pregnant women may be seized with signs of weakness 
which, she has been taught, indicate bleeding, either 
internal or external. When such symptoms are present 
the patient should be put at absolute rest in bed and the 
doctor summoned as speedily as possible. The nurse 
will find the patient's pulse rapid and feeble, her color 
pallid, her skin relaxed and clammy, a desire for more 
air or for water, and dimness of vision present. If 
possible, the nurse should have in readiness hot sterile 
water, and an abundance of clean linen by the time the 
doctor arrives. If there is an antiseptic in the house, it 



ENLARGED VEINS. IO9 

must be in readiness for his use. Whiskey or brandy 
and ice should also be ready. The nurse must expect 
that some form of obstetric operation will be done, and 
should be prepared for this if possible. 

Another very dangerous form of hemorrhage is that 
which occurs when the ovum remains outside the womb, 
and when the sac containing the ovum or the tissue sur- 
rounding the ovum suddenly bursts. This bleeding is 
internal, and follows sharp pain in the abdomen. There 
are rapid pulse, pallor, and clammy skin, and uncon- 
sciousness with great faintness is also present. It is the 
nurse's duty to recognize the gravity of the symptoms, 
and to insist upon medical aid as soon as possible. 
Meanwhile she should prepare for a surgical operation 
as well as she can. 

Enlarged Veins. — The veins of the lower extrem- 
ities often become considerably enlarged during preg- 
nancy. Should such a patient bruise her Hmbs a vein 
might rupture and serious bleeding follow. Should the 
nurse be present at such a case before the doctor could 
arrive, she should place the patient on her back, elevate 
the limb from which the bleeding is coming, and apply 
over the point of bleeding a perfectly clean compress 
several inches square. This may be held by the hand 
until the doctor arrives. If the limb be bandaged, the 
bandage must begin at the toes and encircle the entire 
limb from the toes to the groin. The nurse must be 
careful to have an absolutely clean compress, as septic 
infection might follow the use of soiled material. 

Before rupture, however, the vein should be supported 
by the use of flannel or Jaeger woolen bandages. These 
are more comfortable than silk or silk and rubber, are 
readily washed, and easily applied. They should be cut 



no THE ACCIDENTS OF PREGNANCY. 

from loose flannel three inches wide. To apply such a 
bandage the patient should lie upon her back and the 
limb should be elevated to a moderate degree. The 
bandage should begin at the toes and cover the lower 
extremity completely, omitting, of course, the heel. 
The bandage should extend beyond the point where the 
veins are enlarged ; and if there is a tendency to swell- 
ing in the entire limb, the bandage should extend nearly 
to the groin. The bandage may be removed at night 
when the patient retires, and the limb bathed and the 
skin kept as clean as possible. In some cases obstinate 
itching accompanies this condition, which is greatly 
relieved by bathing with warm water and sodium bicar- 
bonate, or by using some lotion which the attending 
physician may prescribe (Fig. 20). 




Fig. 20. — Spiral reversed bandage of the lower extremity. 



Rupture of Membranes.— The membranes may 
rupture prematurely during the latter part of pregnancy, 
occasioning fright and distress to the patient. Those 
pregnant for the first time should be warned regarding 
the amniotic liquid, as otherwise considerable alarm will 
be occasioned. In some instances the patient wakes in 
bed to find her clothing and the bed very much soiled. 
In other cases the discharge occurs when she is in the 
erect posture or upon slight exertion. In some cases 
the amount of amniotic fluid is very large, so that the 



CONVULSIONS (eclampsia). Ill 

patient may discharge from two quarts to a gallon of 
fluid. 

The discharge of amniotic liquid usually means that 
labor is about to begin. It may indicate the presence of 
complications with either the mother or the child ; hence 
the physician should be informed promptly when amniotic 
liquid escapes. In reporting this and other occurrences, 
if the nurse cannot telephone to the physician personally, 
she should write a note stating as accurately as possible 
what has happened. This will enable her to avoid un- 
necessary alarm to the family and will greatly aid the 
physician. 

When amniotic liquid escapes the nurse should have 
the patient empty the bladder if possible, and should then 
wash the external parts thoroughly and make them anti- 
septic with an antiseptic solution. A sterile vulvar dress- 
ing should be applied with a T-bandage, and the patient 
should be put to bed until the doctor arrives. The nurse 
should comfort the patient by stating that this is not a 
dangerous occurrence, and that it does not necessarily 
mean harm to her child. It does not always mean a 
premature birth, for in some cases the amniotic liquid 
forms again and the patient goes on to the usual termina- 
tion of pregnancy. 

Convulsions (lEclampsia). — A pregnant woman 
may be suddenly seized with convulsions. These usually 
resemble very closely epileptic fits. The patient becomes 
suddenly unconscious, moves the limbs violently, froths 
at the mouth, becomes blue in the face and neck, and after 
a few moments slowly regains consciousness. Occasion- 
ally convulsions begin with acute mania. The patient 
becomes violent, and may attack a friend or relative. 

In the presence of convulsions medical help must be 



112 THE ACCIDENTS OF PREGNANCY. 

summoned at once. The nurse should try to open the 
patient's jaws and get between the back teeth a pad com- 
posed of a folded napkin or towel. This will prevent the 
patient from seriously wounding the tongue. The patient 
should be put to bed and undressed as soon as possible, 
and the nurse should prepare for an obstetric operation 
or a labor. An abundance of hot water, clean linen, 
stimulants, a syringe for injections into the bowels and a 
syringe for vaginal injections, blankets, rubber sheets, and 
several clean pitchers should be placed in readiness. 
Upon his arrival the physician may give medicine by 
hypodermic injection or in the rectum, may desire to 
give the patient a hot bath or hot pack, or may per- 
form an operation. Should the convulsions return be- 
fore the doctor arrives, the nurse should keep the 
patient upon the bed and keep the jaws asunder by 
the pad which we have just described. If the jaws are 
so firmly closed that they cannot be opened by the finger 
covered by a towel, the nurse may try to introduce some 
smooth and blunt object between the teeth. Such would 
be a clothes-pin, or a heavy ivory paper-cutter, very 
blunt and wrapped in a towel or napkin. No more serious 
complication for mother and child can arise than convul- 
sions, and the nurse is justified in insisting upon the 
immediate presence of a physician. 

Syncope. — Pregnant patients sometimes have attacks 
of syncope which are alarming, but which are not often 
dangerous. They result from fatigue, from being in a 
hot and close room, or from exposure to the heat of the 
sun, or from some sudden fright or shock. If the nurse 
is called upon to take charge of such a case, she should 
make the patient lie down with her head as low as possi- 
ble, loosen her clothing, give her plenty of fresh air and 
a little stimulus. A teaspoonful of whiskey or brandy in 



SYNCOPE. 113 

a little hot or cold water, or a teaspoonful of aromatic 
spirits of ammonia in water, is usually sufficient. The 
patient should lie quietly until she has completely 
recovered, when she may be taken to her home in some 
suitable conveyance. A nurse of experience will readily 
detect the difference between convulsions and syncope — 
the one a terrifying and dangerous complication, and the 
other not often indicative of great danger. 



CHAPTER IX. 

THE ACCIDENTS OF LABOR. 
HEMORRHAGE DURING AND AFTER LABOR. 

During" labor the mother may bleed from disease ot 
or accident to the placenta, or from a very extensive 
laceration. Should bleeding occur during labor, all that 
the nurse can do will be to send at once for the physician 
if he be not present, to have ready a copious supply of 
hot water, and to give the patient not more than a tea- 
spoonful of whiskey or brandy every hour. 

After the child is born the nurse should watch the 
patient for signs of bleeding, and if she sees the mother 
suddenly becoming pale she should at once place her 
hand upon the abdomen and try to outline the uterus. 
It should be a hard mass reaching to the umbilicus. If 
the abdomen feels like a pan of dough, and if blood is 
coming from the vagina, the physician must at once be 
informed, and must take steps to secure the prompt 
expulsion of the placenta. In such a case as this a hot 
vaginal douche will be necessary, and in some patients 
a hot intra-uterine douche as well. 

After the placenta has been expelled the doctor will 
usually satisfy himself that the womb is well contracted. 
Should he not do so, the nurse should watch the patient 
as carefully as possible, placing her hand upon the uterus 
at frequent intervals and watching closely for the general 
signs of bleeding. When the nurse is told to clean and 
dress the patient, if the flow is very bright in color 
114 



POST-PARTUM BLEEDING. Il5 

and is excessive, she must at once inform the physician. 
Should bleeding come on very soon after the birth of 
the child, the physician is usually present, and will 
assume the active part in the treatment of the case. 

Physicians differ greatly in their care of women in 
confinement. Those who are cautious will not leave the 
patient's house for at least one hour after the birth of 
the child. Others do not think this necessary, but leave 
so soon as they find that the uterus contracts, and that 
there is no laceration which requires closing. This throws 
an increased burden upon the obstetric nurse, as bleed- 
ing may come on at any time immediately after labor. 
If a physician wishes to help a nurse in these cases, he 
will remain by the bedside of the patient, watching the 
contraction of the uterus and her general condition, until 
the nurse has had time to remove soiled linen and dress- 
ings from the room, to make the patient absolutely clean 
and comfortable, and to wash and dress the child. It is 
a great help to obstetric nurses when a physician takes 
these precautions. 

Post-partum bleeding usually occurs within the 
first three or four houf s after the birth of the child. The 
patient becomes pale, feels Hke fainting, complains that 
the room is dark, that she is thirsty, is restless, and may 
have slight pain in the abdomen. Blood may flow very 
freely from the vagina ; or but very little blood may es- 
cape because a clot forms in the neck of the womb, like 
a cork in the neck of a bottle, and holds back the blood. 
The abdomen feels like a mass of dough, the womb can- 
not be distinctly felt, the patient's pulse is from lOO to 
1 20 or 1 30. The condition is one of great danger, and 
the nurse must immediately send for the doctor, and act 
at once. 



1 1 6 THE A CCIDENTS OF LABOR. 

What the Nurse Must Do. — The nurse should do these 
things in the order given : First. Rub the abdomen from 
above downward until she can feel the uterus. Then 
grasp it firmly by carrying the fingers behind the womb 
as deeply as possible into the pelvis, and, placing the 
thumb firmly upon the anterior surface of the womb, 
the womb should be bent forward over the pubic bone 
and brought as closely against the pubic bone as possible. 
Second. The nurse should have anyone who can help 
her bring the douche-pan or bed-pan in use, a fountain- 
syringe, and three or four toilet pitchers of water at a tem- 
perature of 1 15° to 120° F. Without removing her hand 
from the uterus, with the other hand she should introduce 
the douche-nozzle into the vagina, having first thoroughly 
soaked the douche-nozzle in the hot water, and, having 
her helper hold the douche-bag and pour in the water, 
she should g\Y^ a hot vaginal douche of one gallon. 
She should rub the uterus gently while giving the 
douche, and continue to carry it downward and forward. 
Third. If the patient can swallow, the nurse should give 
her by the mouth two teaspoonfuls of fluid extract of 
ergot. 

While she is doing these things a messenger should 
go for the doctor as rapidly as possible. Meanwhile the 
nurse must not become frightened or alarm her patient. 
Whoever helps the nurse will usually appreciate that 
something is wrong, but the patient if possible should not 
become alarmed. In most cases what we have described 
stops the bleeding or makes it much less. If the patient 
is greatly prostrated, the bed should be drawn out from 
the wall, and the foot of the bed raised until the head 
and shoulders are very much lower than the patient's 
hips. It is perfectly useless to raise the foot of a 
bed six or eight inches and expect benefit from it. 



POST- PA R TUM BLEEDING. 1 1 / 

Very few beds found in private houses can be raised 
sufficiently to accomplish good. 

If the doctor does not come promptly, the nurse 
should continue to grasp and massage the uterus gently ; 
and, should bleeding return, she may repeat the hot vagi- 
nal douche. The pillow should be removed from beneath 
the patient's head. She cannot leave the patient because 
she must control the contraction of the uterus. If help 
does not come for one hour after the giving of the first 
dose of ergot, she may give one drachm in addition. 

If at the end of an hour the doctor does not arrive, 
and the uterus shows a tendency to relax and to bleed, 
if the nurse has with her a hypodermic syringe she may 
give an injection of strychnin (-^ or -^-^ grain). The pa- 
tient may also have one teaspoonful of brandy in hot 
water, and the brandy may be repeated in one-half hour. 
The patient must be kept absolutely still. Her bed may 
be wet and soiled, but she must endure this discomfort 
rather than have bleeding set up by moving her. Blankets 
should be wrapped about her legs, a hot-water bag cov- 
ered by a piece of flannel, or a towel should be placed 
under the back of the neck at the base of the brain, her 
head should be as low as possible, and she should be 
encouraged to believe that in a short time she will be 
comfortable and well. We can scarcely imagine a case 
in which, within three or four hours from the beginning 
of bleeding, a physician could not be found to assume 
the responsibility. Usually, in the hands of good 
nurses, the physician who comes to a case of post- 
partum bleeding arrives to find the hemorrhage stopped 
by the prompt and skilful action of the nurse. 

To Prevent Return of Bleeding. — When the hemor- 
rhage is checked the doctor will take precautions to pre- 
vent its recurrence. Among others he may ask the 



Il8 THE ACCIDENTS OF LABOR. 

nurse to apply some form of binder especially adapted 
to hold the womb in contraction. A box binder is made 
as follows : Three large towels are rolled firmly and the 
rolls pinned or stitched. The uterus is made as small as 
possible by massage, and is carried down against the 
pubic bone. One towel is placed across the abdomen 
above the uterus, and one towel is placed upon each side 
of the uterus, so that the womb is put in a box, one side 
of which is the pubic bone, the other three sides being 
the three tow^els. The abdominal binder is then pinned 
over the womb and these towels, beginning from above 
and pinning downward. This holds the womb firmly, 
while the pressure upon the abdomen is of benefit to the 
patient in a general way. Some physicians prefer a large 
pad placed upon the womb underneath the binder. The 
nurse is sometimes ordered to bandage the patient's limbs 
after hemorrhage. 

Transfusion. — In some cases the physician performs 
transfusion of normal salt solution, introducing it beneath 
the skin or injecting it directly into a vein. The nurse 
should understand the preparation of normal salt solution 
for this and other purposes. It is not necessary to make 
the solution chemically exact, and in an emergency one 
teaspoonful of salt to a pint of water may be employed. 
Some physicians prefer one teaspoonful of table-salt and 
one teaspoonful of pure sodium bicarbonate to a quart 
of warm water. If the solution be prepared at a tempera- 
ture of iio° F., before it can reach the interior of the 
body it will usually fall to 105° or 100° F. The nurse 
must take care that vessels in which this fluid is placed 
have been thoroughly scalded, and that the water has been 
thoroughly boiled before it is introduced into the body. 

Tamponade. — Physicians sometimes introduce anti- 
septic gauze within the womb to prevent the return of 



PROLAPSE OF THE UMBILICAL CORD. I I9 

hemorrhage. For this the nurse should place the patient 
across the bed, her hips at the edge of the bed, her feet 
and legs on chairs. The patient should be moved as 
gently as possible. The physician will require an anti- 
septic solution, a perfectly clean or sterile towel, and 
materials for cleaning and making antiseptic his hands, 
while the few instruments required should be boiled be- 
fore they are used. 

Co7ivalescence. — A patient who has had severe bleed- 
ing recovers slowly from her confinement. If she be- 
comes infected, she is usually very ill. During her re- 
covery she will require very careful feeding and the best 
of nursing to bring her back to good health. After 
severe bleeding sudden excitement and all disturbance 
of the patient must be avoided. She must not sit up 
suddenly, nor rise up quickly in bed, lest a serious acci- 
dent to the heart or brain should occur. 

PROLAPSE OF THE UMBILICAL CORD. 

Occasionally during labor the umbilical cord emerges 
or prolapses from the womb. It is seen in the vagina, and 
if the accident has happened but recently, the cord still 
beats or pulsates. The accident is dangerous for the 
child because the cord may be pressed upon, thus shut- 
ting off the circulation of blood in the placenta, depriv- 
ing the child of oxygen, and producing its death by 
asphyxia. 

Should this occur when a patient is without a physician 
in charge, or a nurse alone, the nurse should send for the 
doctor as soon as possible ; she should put the patient in 
bed \{ she is not already there, cause her to turn upon 
her left side with her thighs flexed, and urge her to refrain 
from straining and bearing down. Having made her 



I20 THE ACCIDENTS OF LABOR. 

hands aseptic, the nurse should then take the cord in 
her fingers and gently carry it within the vagina. A 
vulvar dressing should then be placed and retained in 
position by a T-bandage. In this way the cord will be 
kept within the mother's body. 

If the nurse does not succeed in keeping the cord 
within the mother's body, the cord which is prolapsed 
should be wrapped in a sterile towel, wrung out of sterile 
warm water. The cord should be kept warm and moist 
until the physician arrives. 

A nurse can sometimes succeed in getting the cord 
retained if she places the mother in the knee-chest pos- 
ture, then, replacing the cord within the vagina and draw- 
ing back the perineum, the cord will sometimes pass up- 
ward into the womb. 

The nurse must be very gentle in her manipulations, 
for she can easily do considerable harm. 

ASPHYXIA OF THE CHILD. 

When the child is born it usually breathes and cries 
within a few moments after the umbilical cord ceases to 
beat. If the cord is not beating when the child is born, 
the child must breathe and cry if the action of its heart 
is to continue. When breathing does not commence 
help must be given at once. This must be done by the 
physician, and a nurse cannot be expected to assume this 
responsibility. The physician will require in the treat- 
ment of such a case hot and cold water, several pieces of 
soft, clean old linen, whiskey or brandy, a large basin or 
baby's bath-tub, and several soft, small woollen blankets or 
shawls. The treatment consists in performing artificial 
respiration, in stimulating the action of the heart and the 
lungs by placing the child in a hot bath (temp. ioo° F). 




Fig. 21. — Grasping the child to perform artificial respiration. 




Fig. 22. — Folding the child to cause expiration. 



1 


'4 








^ " 


rmmmmmm 




jflH 


1 


'ys'^H 




t^ 


m 






»..^i^^^^^^H 


Hi 


iJ 





Fig. 23.— Unfolding the child to cause inspiration. 



AR TIFICIAL BREA THING. 121 

and sprinkling or spraying its chest with cold water, and 
by using stimulants by dipping the finger in whiskey or 
brandy and inserting it into the child's mouth, to stimu- 
late the movement of breathing. 

Cleansing the Mouth. — It is especially important 
that the child's mouth be cleansed before the effort is 
made to induce breathing. The infant should be firmly 
grasped by both legs and held with the head downward. 
Placing one hand upon the forehead and raising the head 
gently, the mouth should be thoroughly wiped out with 
the other hand with a small bit of soft old linen dipped 
in boiled and sterile water. The child must be kept sus- 
pended by the legs for several minutes until mucus has 
had a chance to come out of its mouth. 

Artificial Breathing.— There are several methods 
of making artificial breathing suitable for a child. We 
shall describe only the simplest which we think a nurse 
would be justified in employing. Some methods should 
be carried out by physicians only. 

The child should be grasped by the two hands, one 
hand placed across its back at the shoulder-blades, the 
fingers coming upon the anterior surface of the chest. The 
other hand grasps the body by the thighs and pelvis. 
The child should be held with the hips considerably 
higher than the head. It should then be folded and un- 
folded, bending the trunk of the body forward very 
gently but firmly until the abdomen is distinctly squeezed 
and forced up against the chest. Then the body is un- 
folded or unbent until the child is bent slightly backward 
(Figs. 21, 22, 23). This should be done at regular intervals, 
counting one, two, three, four, between the movements. 
After making six of these movements the nurse should 
pause a moment to see whether breathing does not begin. 



122 THE ACCIDENTS OF LABOR. 

The constant tendency must be to keep the child's head 
low and its hips high, so that blood may be kept in the 
brain and mucus may find its way out of the mouth. 

Stimulation. — If the child begins to make move- 
ments of respiration, it should be placed in a warm bath 
and its body gently rubbed until the skin becomes thor- 
oughly red. If breathing continues, the child may then 
be taken from the bath, quickly dried, wrapped in warm 
blankets, and turned upon its right side. Ten drops of 
whiskey or brandy in a teaspoonful of hot water may be 
introduced into the mouth with a medicine-dropper as far 
back as possible. A method of producing breathing often 
used in adults may be employed with children. This 
consists in placing the child upon its back, and a small 
roll made of a sheet or blanket underneath the shoulders, 
so that the head drops slightly backward. The nurse 
stands at the child's head, and taking both arms draws 
them upward and outward as far as she can. The arms 
are then brought downward, inward, and forw^ard in such 
a manner that the chest of the child is compressed, the 
arms being folded across the chest. It is well to have 
the mouth kept open slightly, and if possible the tongue 
drawn forward. These motions should be repeated, 
counting four between each motion. 

Favorable and Unfavorable Signs.— So long as 
the child remains red in color there is good hope that it 
will live. When, however, it is pale and bluish, its limbs 
making no resistance to movement, it is in great danger 
of death. If the finger-tips be placed over the heart 
and the child's body bent forward, the heart can usually 
be felt to beat if life still continues. So long as the child 
is red or reddish in color we must not give up hope nor 
discontinue efforts to bring about breathing. 



CHAPTER X. 
OBSTETRIC SURGERY, 

Obstetric operations are performed to save the lives of 
mother and child ; or if the hfe of the child cannot be 
saved, to rescue the mother if possible. No surgeon but 
the obstetric surgeon has the responsibility of two lives 
in one operation. The most serious complication may 
arise almost without warning during an obstetric opera- 
tion. Hemorrhage and septic infection must be avoided 
as in other surgical procedures. It is evident that the 
obstetrician and the obstetric nurse must be as careful, 
prompt, and diligent in the performance of their duties as 
are those who practise other branches of major surgery. 

In Private Houses. — As many of these operations 
are done in private houses, the obstetric nurse must pre- 
pare from the furniture of the private house a suitable 
operating-table or bed, and other appliances furnished by 
hospitals. The low, very wide bed commonly found in 
private houses is exceedingly objectionable for obstetric 
operations. Neither doctor nor nurse can work to 
advantage with the patient upon such a bed. If a narrow, 
high bed cannot be procured, it is much better to use a 
table the size and shape of the ordinary kitchen-table. 
This should be clean, and covered with a blanket, rubber 
sheet, and clean linen ; and after the patient has been 
anesthetized in her bed she may be lifted on to the table. 
Should the obstetrician desire the Trendelenburg posture, 
it may be obtained by raising the foot of the table in any 
convenient way, or by taking a large rocking-chair. 

123 



124 OBSTETRIC SURGERY. 

removing the legs, and placing the chair with the seat and 
tip of the back upon a table. This forms an inclined 
plane, the patient's legs hanging over the under surface 
of the chair seat, while her body rests upon the back of 
the chair, suitably covered with blankets and rubber 
sheeting. 

In addition to an operating-table, small tables are use- 
ful, upon which sterilizers, basins, and dressings may be 
placed. Tables used for cutting out clothing are very 
useful for this purpose. If suitable tables cannot be 
obtained, kitchen chairs having a large, firm wooden bot- 
tom will be found convenient. The nurse should avoid 
in obstetric operations damage to the patient's furniture. 
If instruments be sterilized upon a highly pohshed table, 
the varnish of the table will often be ruined. Antiseptic 
solutions may be spilled or may spatter upon finely 
polished furniture, injuring the polish. It is always much 
better to use the kitchen furniture if it is reasonably clean. 
Carpets are in danger of injury from the same cause, and 
the floor beneath the edge of the bed must be protected 
by rubber sheeting or by thick layers of paper, or by an 
old thick rug or any other convenient material, covered 
by sterile sheets or sheets wrung out of bichlorid of 
mercury solution, i : 2000. 

Steriliziiig Utensils. — Domestic utensils must often be 
employed for obstetric operations. China basins from 
toilet sets should be prepared by thorough scrubbing 
with soap and hot water, rinsing, and then scrubbing with 
bichlorid solution (i : looo). Toilet pitchers for sterile 
water should be prepared in the same way. Water may 
be sterilized by boiling in tea-kettles or in any other 
suitable vessel which is clean. To measure antiseptic 
solutions, domestic quart measures must often be em- 
ployed, and these must be made as sterile as possible. 




Fig. 25. — Sterilized leggings and sheet for covering limbs and abdomen. 



PREPARATION OF PATIENT. 1 25 

Clothing. — In obstetric hospitals, sterile clothing is pre- 
pared for the lower extremities of the patient during an 
operation. This is not always used in private houses, but 
the lower limbs are covered with long stockings, and 
the thighs may be wrapped in sterile sheets or in large 
sterile towels (Fig. 25). Sterile pillow or bolster covers 
may be utilized. 

Light. — To secure an abundance of light for an obstetric 
operation in a private house is not always an easy matter. 
A candle in a firm candlestick should be in readiness if 
light fails, as the obstetrician will often utilize the candle 
for the examination of lacerations or to insert stitches. 

Preparation of Patient. — To prepare a patient for 
an obstetric operation, the nurse should ask the physician 
what method of preparation he desires, and whether he 
wishes the nurse to catheterize the patient. If he gives 
no definite instructions, and if he tells the nurse to 
catheterize the patient, she may proceed, we think, properly 
as follows : The external parts, including the hair above 
the pubes, should be very thoroughly washed with soap 



Fig. 26. — Glass female catheter. 

and warm water. The hair should be trimmed short with 
scissors curved upon the flat or removed by shaving. The 
parts should be very thoroughly rinsed with hot water ; 
and if the patient's bowels have not been emptied by 
enema the rectum should be very thoroughly washed 
out with hot soapsuds. Then the parts should be 
scrubbed with cotton or gauze dipped in bichlorid solution 
(i : 2000). Having sterilized the catheter by boiling, and 



126 OBSTETRIC SURGERY. 

having very carefully scrubbed and made antiseptic her 
hands, the nurse should then catheterize the patient. 
After this the tissues about the meatus should be again 
thoroughly douched with the bichlorid solution. 

The physician should specify whether he desires a 
vaginal douche given ; and if so, what the douche should 
be. Many physicians prefer lysol in i per cent, solution, 
because it does not injure the hning membrane of the 
genital tract, but leaves it in a favorable condition for 
the passage of the fetal head. No douches should be 
given without the doctor's order. 

Anesthesia. — The anesthetic for an obstetric opera- 
tion should be administered by a physician with the 
same precautions used in any other surgical procedure. 
The difficult extraction of the child is as serious an 
operation as the removal of an ovarian tumor. Hence 
the same precautions in the care of the patient should 



Fig. 27. — Hypodermic syringe. r\ 

be taken. No nurse should undertake the responsibility 
of giving an anesthetic for an obstetric operation. If the 
physician first anesthetizes the patient and then tells the 
nurse to continue the anesthesia, she may do so upon 
his responsibility. The anesthetizer should have a hypo- 
dermic syringe with tablets of strychnin, atropin, and 
other stimulants, whiskey or brandy, should be in readi- 
ness, several small soft towels and a small basin should 
the patient vomit. Considerable suffering may be avoided 
if the nurse rubs upon the patient's lips and about her 
nostrils a little cold cream or vaselin before the anesthetic 
is administered. 



ANESTHESIA BY THE NURSE. 12/ 

Anesthesia by the Nurse. — If it can possibly be 
avoided, the nurse should not undertake the responsibility 
of giving anesthetics to surgical anesthesia for a consider- 
able time. This procedure requires the training and ex- 
perience of a physician, and very serious consequences 
may follow the ignorant or careless giving of anesthetics. 

Occasionally in obstetric operations where no other 
help can be obtained, the nurse must give the anesthetic 
under the doctor's supervision. In these cases the 
doctor will first administer the anesthetic until the patient 
is practically under its influence. He will then give the 
cone or inhaler to the nurse, instructing her whether she 
is to put it directly over the patient's mouth, or whether 
it is to be held at some distance from the face. If ether 
is used, the cone, or gauze, or inhaler, may be held 
much closer to the patient than if chloroform is given. 
A larger quantity of ether than of chloroform can be 
taken. If chloroform be administered, the cone or in- 
haler should not be used by the nurse, but a piece of 
gauze or a clean handkerchief or napkin should be taken 
instead. This should be held about two inches from the 
patient's nostrils, allowing air to enter the nose and 
mouth freely. A few drops of chloroform at a time should 
be dropped upon the gauze or handkerchief, and no large 
amount of chloroform should be poured from the bottle 
at any one time. Patients often breathe more quietly 
with chloroform than with ether, but sometimes cases of 
heart failure occur under chloroform, which develop sud- 
denly and to an alarming extent. When the nurse is 
giving chloroform, she should watch carefully the patient's 
color, and, if possible, observe the condition of the pulse. 

When ether is given, the patient's mouth and nostrils 
should be anointed with a clean ointment to prevent the 



128 OBSTETRIC SURGERY. 

irritating effects of the anesthetic. If gauze is used it 
may be laid over the mouth and nostrils in several 
layers, and the ether, dropped almost continuously upon 
the gauze. 

During anesthesia the patient's tongue may drop back 
into the throat, covering the entrance to the windpipe or 
trachea and lungs. This will prevent respiration, and 
unless it be remedied, the patient may die. In these 
cases the jaws very frequently become set, the tongue 
may be pinched or bitten, and it is very difficult to open 
the mouth. 

To prevent this during anesthesia the nurse should 
place the thumbs deeply under the angle of the jaw. 
The jaws should then be raised and drawn forward, when 
the base of the tongue will be raised, and air will gain 
access through the trachea. If this does not succeed the 
mouth must be opened as quickly as possible, the tip of 
the tongue seized, and the tongue drawn strongly forward 
and downward. 

During anesthesia the nurse should take the precau- 
tion to keep between the patient's teeth the end of a 
folded napkin or handkerchief to prevent the jaws from 
coming tightly together. 

If at any time during anesthesia the patient's color 
becomes a whitish-blue, or the patient breathes badly, 
the physician must be immediately notified. 

When the patient is recovering from the anesthesia she 
requires attention. Before she becomes conscious the 
tongue may drop back over the trachea, which would 
greatly interfere with her breathing. 

If the patient vomits, a piece of food or a mass of 
mucus may get into the larynx and threaten suffocation. 
A firm clot of milk, or a piece of half-digested meat is 



INSTRUMENTS. IIQ 

especially dangerous. The patient should not be left 
without care after anesthesia until she is quite conscious 
and fully able to free the mouth of any material which 
may collect there. 

The nurse can do much for her patient in encouraging 
and comforting her, should an obstetric operation be 
necessary. Many women shrink from such because they 
fear that the operation will injure the child. The nurse 
should explain that the operation is undertaken in the 
interests of the child as well as the mother, and that 
it is far better for the child than to delay. In this way 
the nurse can give great assistance to the patient and 
to the physician as well. During obstetric operations 
no one should be present, if it can possibly be avoided, 
except physicians and nurses. Occasionally some self- 
possessed person may be useful as an assistant. 

The nurse must have ready hot-v/ater bags or hot- 
water bottles to secure a good reaction after the opera- 
tion. It is much better to remove the patient from her 
bed for the operation, as she may then be placed upon 
clean, dry linen immediately after. If the family do not 
realize the fact, they must be told that she will not 
recover from the effects of the ether for a short time, 
and so their apprehension may be allayed. 

Instruments. — The physician will bring with him his 
instruments and gloves and the sterilizer in which they are 
to be prepared. The most convenient and simple apparatus 
is a tray or pan covered by a second slightly larger than 
the first. Instruments can be boiled in such by the use 
of an alcohol lamp or by placing the pan upon a stove. 
Some physicians prefer to add a tablespoonful of sodium 
bicarbonate to the water in which their instruments are 
boiled, while others use a i per cent, solution of lysol. 



130 OBSTETRIC SURGERY. 

Some employ carbolic acid in i or 2 per cent, solution. 
When the instruments have been boiled the upper pan 
or tray is removed, turned over, and placed beside the 
first. This gives the operator two sterile trays or pans 
in which he may arrange his instruments. Occasionally 
the nurse will find that a physician comes to an obstetric 
case without a sterilizer. Instruments must then be 
boiled in some domestic utensil, which is a very unsatis- 
factory procedure. Nurses must also exercise caution 
in the use of alcohol lamps, placing them on metal trays 
if possible, for we have known of distressing accidents 
from this source. The sterilizer and its lamps may be 
safely placed in an empty bath-tub, which is the most 
convenient method. The bath-room is usually the most 
available room for the nurse's preparations. 



DELIVERY BY FORCEPS. 

Instruments. — The obstetric forceps is an instrument 
composed of two parts resembling a pair of human hands 
and arms, applied to the head or body of the child to 
extract it from the mother. The two portions of the 
instrument are called blades, the left and the right. 
They are placed one above the other, crossing each 
other, and fastened together about the middle by a device 
called the lock. When a nurse is told to prepare the 
forceps for use it is meant that she should sterilize them. 
They should be kept in the solution in which they are 
sterilized until the physician applies them to the child. 
If they are not sterilized, the physician will sometimes 
order them placed in a toilet pitcher of antiseptic fluid, 
the larger portion downward and the upper part, or 
handles, above. The pitcher is covered with a clean 



INSTR UMENTS. 



131 



towel, and is placed upon the floor at the side of the 
physician. Cases in which it is necessary to dehver by 
forceps are often those in which a laceration of the 




Fig. 28. — Davis's obstetric forceps. 



mother's tissues is inevitable. Physicians usually pre- 
pare instruments for closing lacerations when they prepare 




Fig. 29.— Kelly's cervix needles. 



Fig. 30. — Cervix needles, a, Emmet's round 
point; b, Hank's double edge, stout; c, d, Sims' 
concave point, straight and curved ; e, Skene's 
trocar point. 



the forceps. These are needles and needle-holder, hemo- 
static forceps, scissors, tenaculum forceps, and uterine 
dressing-forceps. As it may be necessary in these cases 



132 



OBSTETRIC SURGERY. 



to give a vaginal or intra-uterine douche, a douche-tube 
should be boiled with the other instruments. Some phy- 
sicians prefer to sterilize a strip of gauze with the instru- 




FiG. 31. — Volsella forceps. 



ments, as such is occasionally required after the operation. 
In other cases the gauze is kept in the glass jar or bottle 




Fig. 32. — Tenaculum forceps. 



in which it is purchased, and is removed from the jar 
only at the moment when it is used. Suture material is 




Fig. 33. — Davis's uterine dressing-forceps. 



often sterilized with the instruments. If possible, instru- 
ments should be boiled for from twenty minutes to one- 
half hour. 



PREPARATION OF PATIENT. 



133 



Preparation of Patient. — For forceps operations 
the patient is usually placed upon her back at the edge 
of the bed or table. Beneath her should be a rubber 
sheet or Kelly pad (Fig. 34), and a slop-jar to receive 
douche-water and discharges. Occasionally the patient 
is turned upon the side, usually 
upon the left side. In hospitals, 
where there is an abundance of 
assistants, each lower extremity 
may be held by a nurse. In 
private houses it is well to use 
some simple device which will 
support the limbs. Of these, the 
best is a sheet folded in the longest 
way, so as to make a band six or 
eight inches wide. When the 
patient is anesthetized and placed 
in position, her legs are flexed 
upon the thighs, and the thighs 
upon the body. The sheet is then 
placed across the patient's shoul- 
ders just below the neck, passed 
on the outer side of each lower 
extremity, and tied around the 
leg just below the knee. In this 

way the Hmbs are drawn backward and rotated outward. 
Assistants are not required to hold the limbs, and the 
posture is a convenient one for the operator. Over the 
limbs and abdomen sterile Hnen should be applied. 
Should the obstetrician prefer, he may employ Kelly's 
or Robb's leg-holder (Fig. 35), made for this purpose. 
After the patient has been placed in position, the limbs 
supported, the lower half of her body should be covered 




Fig. 34. — Kelly pad. 



134 



OBSTETRIC SURGERY. 



by a sterile forceps sheet. This consists of two large and 
long legs joined above by a square sheet large enough to 
cover the abdomen. This is drawn over the limbs and 
abdomen from below upward. 

Nurse^S Duties. — Beneath the edge of the bed or 
table should be placed some material to protect the 
carpet. The physician's forceps and other instruments in 
the sterihzing pans should be 
placed upon chairs or a table 
at his right hand, and a basin 
of antiseptic solution with 
gau^e or cotton sponges 
should be in readiness. The 
nurse should prepare the anti- 
septic solution ordered for the 
douche, and also boil the 
catheter. The physician will 
usually order the nurse to 
prepare the patient for the 
application of forceps, and 
this is done as. already de- 
scribed. During the actual 
delivery of the child the nurse 
can sometimes assist with the 
anesthetic or occasionally fol- 
low the doctor's orders in rubbing the uterus and causing 
it to contract. She should be ready so soon as the 
child's head is born to wipe out the eyes and to cleanse 
the mouth, as is done in normal cases. The child is 
often asphyxiated for a few moments after such a deliv- 
ery, and then the nurse may assist in causing it to breathe. 
If possible, a clock or watch should be visible and the 
time of the child's birth should be noted. When the 




Fig. 35.— Robb's leg-holder. The 
leg-holder is made of unbleached can- 
ton flannel and can be washed (Ash- 
ton). 




Fig. 36. — Patient in position for forceps operation, limbs supported by 

sheet. 



WAL CHER'S POSITION. - I 35 

placenta has been delivered and saved for examination, a 
thorough vaginal douche is given as ordered by the 
doctor, ergot or strychnin is usually administered, and 
the physician proceeds to close any lacerations which 
may be present. During this portion of the operation 
the nurse may antisepticize her hands and put on sterile 
gloves and assist the physician by threading his needles 
and sometimes by sponging the parts. Should the 
physician decide to give an intra-uterine douche, the 
nurse must be careful that the fluid is of the exact com- 
position ordered and of exactly the temperature desired. 
The douche-tube must not only have been sterilized, but 
should also be thoroughly rinsed with an antiseptic solu- 
tion before introduction. The usual dressings are applied 
after the stitches have been taken. 

Waicher^S Position. — In cases of forceps extraction 
in which especial difficulty is experienced in causing the 
head to descend the physician may put the patient in 
Walcher's posture. The patient must be placed upon her 
sacrum just above the buttocks at the edge of a table 
sufficiently high so that her feet cannot reach to the floor. 
The lower extremities are then allowed to fall directly 
downward toward the floor. She must be held in this 
position by two assistants, one on each side, grasping the 
sides of the pelvis and preventing the patient from sliding 
off from the table. During the delivery with forceps 
especial care must be taken that the patient does not slip 
down too far. To protect the patient's back, the nurse 
must place upon the edge of the table a blanket firmly 
and smx)othly folded, or a folded sheet covered if possible 
with some woollen material. The lower extremities must 
be covered with suitable leggings or wrapped in sheets or 
blankets pinned about the limbs with safety-pins. As the 



136 OBSTETRIC SURGERY. 

delivery proceeds the physician may request that the 
thighs be flexed, thus altering the tension of the muscles 
upon the floor of the pelvis. 

VERSION OR TURNING. 

Sometimes it is necessary to turn the child in the 
womb and cause it to be born with the feet and legs first. 
For this operation obstetricians usually prepare the for- 
ceps and instruments just described, because the forceps 
may be used at the latter part of the extraction of the 
child. The patient is prepared as already described, and 
is catheterized. She is placed upon her back with the 
limbs flexed. The physician may turn the child by 
external manipulation, but usually does so by introducing 
a part or all of one hand within the womb. He will 
require material for disinfecting his hands, and usually 
lysol or creolin is used, because it furnishes a lubricant as 
well. A slip-noose of gauze or a strip of sterile linen is 
sometimes employed after version has been completed, 
to hold the child's limb. If the physician orders it, the 
nurse should have it in readiness. After version has been 
completed the birth of the child proceeds slowly until 
the body has been expelled. As the body is expelled 
the nurse should have in readiness several warm towels, 
one of which the physician will wrap around the child's 
body to keep it from becoming chilled. When the head 
is to be born the patient is usually urged to bear down 
strongly and the body of the child is raised toward 
the mother's abdomen. Sometinies it is necessary to use 
forceps to bring out the head, and when this is the case 
the nurse may be told to grasp the body of the child 
wrapped in the towel, and raise it strongly over the 
mother's abdomen. The physician can then apply forceps 




Fig. 37. — Holding the patient in Walcher's position. 



SYMPHYSIOTOMY; PUB 10 TO MY. 1 3/ 

underneath the body of the child. Laceration may occur 
during version and extraction, and the instruments already 
described will be needed for its repair. 

SYMPHYSIOTOMY ; PUBIOTOMY. 

When the pelvis is too small or the child is a little too 
large the pubes may be severed to allow the child to 
escape. This operation is called symphysiotomy or 
pubiotomy. 

The Operation. — The instruments required are a 
scalpel, a fine saw, a probe-pointed bistoury, a sound, 
hemostatic forceps, needles and needle-holder, scissors, 
uterine dres^ng-forceps, antiseptic gauze and a roll of 
surgeon's adhesive plaster, an abdominal binder, and often 
a catheter to which is attached a long piece of rubber 
tubing. These instruments must be sterilized and the 
patient prepared as described. Several assistants are re- 
quired. The patient is placed upon her back at or near 
the end of the table. The limbs are usually extended at 
first, but afterward flexed. After the opening of the pubes 
the delivery of the child is usualfy accomplished by the 
use of forceps. These should have been sterilized wath 
the rest of the instruments and kept in readiness. Lacer- 
ations often occur, which are closed as usual. The 
wound made above the pubes must also be closed by 
suture. 

•The Dressing.— When the pubes is opened the two 
halves of the pelvis gape asunder. When the child is 
delivered these two portions must be brought together, 
and some apparatus is required to maintain them in that 
position. Various sorts of bandages and other restrain- 
ing apparatus have been used. A good and simple dress- 
ing consists of a strip of surgeon's adhesive plaster, six 



138 OBSTETRIC SURGERY. 

to eight inches wide, long enough to go around the pa- 
tient and to overlap. The pelvis of the patient is pressed 
together by two assistants, who grasp her body at the 
hips. An antiseptic dressing is placed over the wound. 
A strip of adhesive plaster from which the muslin has 
not been removed is carried underneath the patient, and 
is pulled tight and smooth by two persons holding the 
ends. The musHn strip is then hastily pulled off and 
the adhesive strip is brought up and around the patient 
in such a way that the center of the strip is directly over 
each trochanter of the femur. The strip is made to 
overlap. Over this is placed an abdominal binder. A 
catheter is often inserted into the bladder and allowed to 
remain. 

The After-care. — After symphysiotomy or pubi- 
otomy the patient must lie upon her back for at least two 
weeks. Her bed must be kept very carefully, and atten- 
tion paid to the skin to avoid bed-sores. It is often hard 
to make the patient realize that it is absolutely necessary 
that she remain upon her back. Such patients require 
the use of a catheter. When the patient is dressed, two 
strong persons stand upon each side, press firmly against 
the sides of the pelvis, the old strip of plaster is quickly 
removed, the skin bathed with soap and water and with 
alcohol, and a new strip is applied. This opportunity may 
be taken to apply alcohol or alcohol and water to the skin 
which is just beneath the plaster, and in this way sore- 
ness can usually be avoided. A patient who does well 
can usually turn upon her side at the end of three or four 
weeks. The plaster strips may be removed, and the pa- 
tient can wear a canvas belt with straps and buckles. 
She is usually well in six weeks after operation. 



EMBR YO TO MY. 1 39 

EMBRYOTOMY (CRANIOTOMY). 

It is sometimes necessary to destroy the child or to 
dismember its body and to bring it away piecemeal. This 
is known as embryotomy. Because the head presents 
most frequently it is most often pierced by such opera- 
tions, and hence the most frequent variety of embryotomy 
is craniotomy. If the child be living, some parents desire 
that the rite of baptism be administered to it before the 
operation is done. As embryotomy is an operation 
shocking to the mother and to her friends, the nurse 
must take care that no description of the operation is 
given to the mother, and that the body of the child is 
kept out of sight. Curious persons may desire to ex- 
amine it, and greatly exaggerated and distressing reports 
may arise from this source. 

The patient is placed in the dorsal posture and anes- 
thetized, the doctor's instruments and other appliances 
being in readiness. A plentiful supply of antiseptic solu- 
tion for a douche must also be ready. The physician 
will extract the child by perforating the head, crushing 
it and delivering, or by opening the head and removing 
the brain. During the extraction of the child he will 
require a plentiful supply of hot antiseptic fluid, as it is 
often necessary to wash out the brain before the body is 
delivered. Lacerations often occur, and instruments and 
appliances must be in readiness for closing them. In 
some cases it is necessary to cut the body of the child 
into several pieces to deliver it. This is usually done by 
the employment of large, blunt-pointed scissors. Care 
should be taken that the body of the child is kept 
covered from the moment it is born. The strictest 
antiseptic precautions must be taken both before and 



I40 OBSTETRIC SURGERY. 

after embryotomy, as many of these cases have been 
long in labor, and some of them are infected before they 
enter a hospital or before the operation is done. 

DELIVERY BY ABDOMINAL SECTION (CESAREAN 
SECTION). 

The Operation. — It is believed that Julius Cesar was 
extracted from his mother by abdominal incision, and 
hence delivery in this way has been commonly called 
Cesarean section. By this operation are meant the open- 
ing of the abdomen ; the opening of the uterus ; the extrac- 
tion of the child, its placenta, cord, and membranes ; and 
the closure of the uterus or in some cases the removal 
of the womb. The mother is exposed to dangers of 
hemorrhage and septic infection, while the child may be 
injured if the operation be not well performed. The 
operation is done in cases in which the pelvis is so small 
that a living and viable child cannot be delivered through 
the usual channel. In some cases the presence of a 
tumor may make delivery by Cesarean section necessary. 
In most of these patients the mother is in a sound and 
aseptic condition before the operation is undertaken. 
Hence the operation is a good test of the asepsis of the 
operator and his assistants, for if infection follows it 
comes most probably through his carelessness or igno- 
rance. In order that Cesarean section may be successful 
the operation must proceed absolutely smoothly. The 
child is born very quickly after the abdomen is opened, 
and should delay occur at this moment the hfe of the 
child may be lost and the mother may be brought into 
great danger. Hence those who assist in this operation 
must understand what is expected of them, and must do 
it carefully and promptly. 



ANTISEPTIC PREPARATION. 14I 

Preparation of Patient. — To prepare a patient for 
Cesarean section, she should be under observation for at 
least a week. The intestinal canal must be thoroughly 
emptied, and such medicine for this purpose as the doctor 
prescribes must be carefully given. The lower bowel 
should be emptied and cleansed by high injections of 
salines and glycerin, of normal salt solution, or any other 
preparation which may be ordered. The patient's skin 
must be made active by a daily warm bath. The diet 
should be limited to liquids or to very simple and easily 
digestible food, and an abundance of w^ater should be 
taken. The physician in charge will examine, or cause to 
be examined, the patient's urine to know whether the kid- 
neys are acting properly. If she has a cough, this must 
be reported to the physician, and any other abnormalities 
about the patient. The physician will decide by con- 
ferring with the patient and her friends as to the sort of 
operation to which she will consent. It is better that 
the patient should be at rest during the greater part of the 
time. She can usually be made comfortable in bed, and 
this will avoid unnecessary fatigue. The nurse should 
encourage the patient in every way and tell her the good 
results obtained by this operation. In most cases in the 
hands of good operators mother and child recover. At- 
tention must also be given to the breasts and nipples, 
because the mother can nurse her child after the opera- 
tion in most cases. The breasts and nipples should 
be washed thoroughly with Castile soap and warm 
water, and the nipples anointed daily with sterile olive oil 
or an ointment which the physician may order. 

Antiseptic Preparation. — The operator should 
give precise and in most cases wiitten directions for the 
antiseptic preparation of the patient. Most operators 



142 OBSTETRIC SURGERY. 

order that the abdomen be thoroughly scrubbed with 
Castile soap and warm water and a soft brush, that the 
hair above the pubes be shaved and the hair about the 
labia be trimmed short with scissors curved upon the 
flat, and that the parts be douched thoroughly with 
boiled water, then scrubbed with alcohol and with 
bichlorid solution (i : 2000). Others prefer the use of 
green soap and alcohol ; and some employ a poultice of 
green soap, which is worn by the patient for eight or ten 
hours. Some operators prefer lysol or carbohc acid. 
After the abdomen has been prepared an antiseptic 
dressing is applied large enough to extend from the 
tip of the sternum to the pubes. This is bandaged 
upon the patient by a many-tailed bandage. Such 
preparation should be made at least tw^enty-four hours 
before the operation and the dressing worn during that 
time. Just before the commencement of the operation, 
and often while the patient is being anesthetized, the 
abdomen may be prepared again in the same manner or 
as the obstetrician may direct. In some cases vaginal 
disinfection is also practised. This is done by a copious 
vaginal douche of tincture of green soap (two ounces to 
one pint of boiled water). The mucous membrane is 
thoroughly scrubbed with pieces of gauze or cotton held 
in uterine dressing-forceps. A copious douche of hot 
boiled water is then given, and after this a douche of 
bichlorid solution (i : 2000). In some cases the operator 
applies a dressing of surgical gauze as well. A bichlorid 
napkin is worn over the vulva until the time of operation. 
Preparations for Operation. — \\ henever possible 
Cesarean section should be performed in the aseptic 
operating-room of a modern hospital. This, however, is 
often not possible, as many of these operations must be 



THE NURSE. 1 43 

done in private houses. If an ordinary room must be 
used and there is time to prepare it, carpets and curtains 
should be taken away, and the floor and as much of the 
room as possible thoroughly scrubbed with soap and 
water. After this a thorough scrubbing with mercuric 
chlorid solution (i : 500) should be practised. An oper- 
ating-table may be improvised by using one or two 
kitchen tables which have been thoroughly scrubbed. 
Pitchers and basins or metal vessels to be used must be 
thoroughly cleansed by scrubbing with soap and boiHng 
water, or preferably by boiling. Sheets, towels, and linen 
to be used must be sterilized by boiling for at least thirty 
minutes. A half-dozen large bottles or small jugs should 
be fitted with tight corks, so that they may be filled with 
hot water and applied about the patient. Before the time 
of operation some reliable person must see that plenty of 
hot water is available. The room must also be heated, and 
an open stove or wood fire is the best heat available. 
If furnace heat is employed, the operating-table should be 
placed as far as possible from the furnace register, and 
over the register there should be tacked several layers of 
cheesecloth or bichlorid gauze to arrest the dust. Over 
the bottom window sash sheets or newspapers should be 
tacked if there is a possibility that anyone may look into 
the room. Several small tables or a number of chairs 
with flat, hard bottoms are needed in addition to the 
operating-table. 

The Nurse. — The nurse must personally be sure 
that she is in an aseptic condition. She must not come 
to a Cesarean case from any contagious or infectious dis- 
order. She should thoroughly cleanse herself by a daily 
bath for several days before the operation, and should 
have the hair thoroughly washed. Her clothing should 



144 OBSTETRIC SURGERY. 

be absolutely clean, the finger-nails trimmed smooth 
and short, and there should be upon the hands no sore 
spot or pimple containing pus or other suppurating sur- 
face. She should wear sterile gloves. She should not 
have a foul discharge from the nose or mouth or from any 
part of the body. If the case be done in a hospital, in- 
struments, dressings, and ligatures will be sterilized in the 
hospital apparatus. If the operation be done in a private 
house, the nurse must choose perfectly clean vessels in 
which the instruments can be boiled and kept. Fortu- 
nately, she will rarely be obliged to do this, as the opera- 
tor will usually bring with him apparatus for sterilizing. 

The part which the nurse takes in this operation will 
depend considerably upon the number of assistants 
present. The operator usually requires an assistant 
who helps him in the operation. Another physician 
gives the anesthetic. Another assistant receives the child 
at the moment of its birth, sees that it breathes properly, 
and ties and cuts the umbilical cord. An experienced 
and self-possessed nurse is perfectly competent to do 
this, and this part is often given to a good nurse. A 
nurse or physician should watch the needles and liga- 
tures, keeping the needles threaded without interruption. 
The same assistant may help with the sponges \i assistants 
are not abundant. It is better if possible to have one 
nurse or one physician give entire attention to sponges 
and dressings. 

Receiving the Child. — Skilful operators can per- 
form the operation in private houses with the assistance 
of two physicians and one nurse. To do this the operator 
must prepare his needles, sutures, ligatures, sponges, and 
dressings before the operation commences. The nurse 
must take the child and give it the first care which it 



NURSE ' S D UTIES. 145 

requires. She prepares a shallow vessel covered by a 
warm blanket or sheet, and, standing at the operator's 
side as he directs, she holds the vessel in her arms. The 
operator, when the uterus is opened, removes the child 
quickly, with its placenta, cord, and membranes, and puts 
the entire mass into the vessel covered by the sheet. The 
nurse then ties the umbilical cord, cuts it, wipes the child's 
mouth and eyes, holds it head downward, and assists its 
respiration in the manner which we have described. Some 
operators hand the child to the nurse, and then tie and 
cut the cord themselves. After the child has been sepa- 
rated from the mother and has breathed, it should be 
turned upon its right side, wrapped in a warm blanket, 
and given to the care of some intelligent person, who 
will watch its breathing and notify the obstetrician if the 
child is not breathing well. 

Nurse^S Duties. — The nurse's duties before the 
operation are to prepare the patient in the manner ordered 
by the obstetrician ; to have on hand such supplies in 
the way of sterile dressings, linen, towels, and solutions 
as he may order ; to see that the room is properly pre- 
pared and at the proper temperature ; and to have ready 
a copious supply of hot water, stimulants, and such 
drugs and medicines as may have been prescribed by the 
doctor. 

During the operation, if ordered to do so, the nurse 
may receive the child and care for it as directed. If this 
duty is given to another, she must assist with dressings, 
needles, sutures, and ligatures as desired, remembering to 
observe strictly antiseptic precautions. Her hands and 
arms must have been made thoroughly aseptic before 
touching sponges, instruments, sutures, ligatures, and 
needles. If by accident during the operation she touches 

10 



146 OBSTETRIC SURGERY. 

any article which is not aseptic, she must at once again 
cleanse her hands and arms. If placed in charge of 
sponges, she must know how many gauze pads and 
sponges she has, and be able to assert that all have 
been returned. Cases are on record where the patient 
has lost her life because a nurse did not know that a 
gauze pad or sponge had been left within the abdomen. 
She must also have knowledge of the number of needles 
and instruments employed. 

After-care. — So soon as the operation is over it will 
be her duty to supply promptly hot bottles, blankets, 
clean Hnen, and stimulants. She must be ready to give 
rectal injections of stimulants if desired. She must 
obtain from the obstetrician written orders regarding the 
treatment of the patient, and she had better insist that 
orders be left in wTiting. She may plead that the responsi- 
bility is so great that she cannot honestly assume it with- 
out written orders. If she is required with the patient, 
she must not neglect the mother to clean the doctor's 
instruments. Nurses sometimes make grave mistakes in 
neglecting a patient to clean the doctor's instruments 
promptly and thus enable him to leave t-he case. 

The after-care of a case of Cesarean section consists in 
the very careful following of the written orders given by 
the doctor. The nurse may be required to give rectal 
injections of stimulating or nutritious substances imme- 
diately after the operation. Hypodermic injections of 
sedative medicines are sometimes used. Nothing should 
be given by the mouth without the distinct order of the 
doctor, and liquid food is usually employed with these 
patients for the first week or ten days. When the patient 
has reacted well from the operation and desires to see 
the child, it may be shown to her, and she may attempt 



CONVALESCENCE. 1 47 

to nurse it. If she does well, she should nurse the child 
afterward at regular intervals. It is usual to move the 
bowels thoroughly two or three days after the operation. 
The patient is given some purgative medicine in small 
doses, followed by salts, and then by an enema or by 
repeated enemas. Enemas of sahne, glycerin, turpentine, 
and soapsuds are usually employed at first. Later, cas- 
tor oil, olive oil with turpentine and soapsuds, or soap- 
suds only are usually given. It may be necessary to 
give this injection as high in the bowel as possible, using 
a long, soft rectal tube and inserting it very gently. 

After-symptoms. — When the nurse is left alone with 
the patient she should watch carefully the condition of 
the pulse, taking the temperature at regular intervals as 
directed by the doctor. Should the pulse become rapid, 
or should the patient complain of pain in the abdomen, 
or should the abdomen become distended, the nurse must 
notify the physician at once. Patients may vomit for a 
while after the administration of ether. This should 
cease within a short time. Should the vomiting not 
cease the physician must be notified. For the first 
twenty-four hours after the operation the patient must 
remain absolutely still. The nurse must exercise the 
greatest watchfulness, and two nurses are needed to 
relieve each other. The child, fortunately, will not 
require much care, as it usually sleeps the greater part 
of the time. It must be put to the breast as ordered, 
and given water from a medicine-dropper or a teaspoon 
in addition. 

Convalescence. — When the patient does well the 
stitches are removed at the end of ten days or two 
weeks ; the patient is allowed light diet at about the 
same period ; she may turn freely upon her side at the 
end of the first week or ten days, and is able to sit up 



148 OBSTETRIC SURGERY. 

in bed at the end of two or three weeks. She is usually 
allowed to leave her bed at the end of the first three or 
four weeks, and is thought to be recovered in a month 
or six weeks after the operation. 

The duties of the nurse are the same in each kind of 
Cesarean operation. In some of these operations the 
womb is sewed together and left in the abdomen. The 
patient may have other children after the operation. 
In other cases the whole or greater part of the womb 
is removed together with the tubes and ovaries. The 
patient cannot have a child afterward. She also ceases 
to be unwell. The patient should nurse her child no 
matter which of these operations is performed, as she 
can do so if she makes a good recovery. 

The Child. — The nurse will be interested in noticing 
that the head of a child born after Cesarean section 
shows no evidence of pressure during birth, but is round 
and well shaped like the head of an infant two or three 
weeks old. The child is usually quite vigorous in these 
cases, as the method of birth is a very easy one for the 
infant. 

THE INDUCTION OF LABOR. 

It is sometimes necessary to bring on the birth of the 
child before the natural time. The duties of the nurse 
with such a patient are to prepare her in accordance 
with the doctor's orders. Usually the bowels are freely 
emptied, the patient is catheterized if necessary, the ex- 
ternal parts are thoroughly cleansed and made aseptic, 
and the vagina is cleansed as the doctor orders. The 
method described in Cesarean section is often used. 
At the appointed time the doctor will have the nurse 
place the patient in position, lying upon her back across 



REPAIR OF LACERATIONS. 1 49 

the bed or table. He will have prepared his instruments 
by sterilization, and antiseptic precautions must be used 
as regards the doctor's hands and gloves and the hands 
and instruments or appliances which the nurse employs. 
The physician will introduce within the womb a bougie 
or elastic bag, or possibly antiseptic gauze, in such a 
manner as to excite uterine contractions and bring on 
labor. This instrument is kept in place by a vaginal 
tampon of antiseptic gauze, and the patient is kept in bed 
wearing an antiseptic napkin and a T-bandage. In some 
cases the doctor will order that the patient be catheterized 
at regular intervals, and in other cases she will be 
allowed to empty the bladder. The nurse in charge is 
expected to report to the doctor the occurrence of labor- 
pains or the discharge of amniotic liquid. Should hemor- 
rhage from the vagina occur, this must also be reported at 
once. If the patient expels the bougie or bag, this should 
be reported. In many cases the insertion of the instrument 
or gauze is done at about the patient's bedtime, when she 
is allowed to rest during the night. On the day follow- 
ing, if labor-pains do not become active, the physician 
may remove the instrument or dressing and replace it 
by others. Should he not do this, he may remove the 
instrument and allow the patient to be up and about as 
usual. Some time is usually required to bring on active 
labor, and vigorous uterine contractions may not be felt 
for several- days. Finally, however, the patient comes 
into labor. 

THE IMMEDIATE OR PRIMARY REPAIR OF 
LACERATIONS. 

A very important obstetric operation for the health of 
the mother consists in closing lacerations of the cervix. 



I50 OBSTETRIC SURGERY. 

pelvic floor, or perineum. In some cases these injuries 
cannot be avoided, and if they be promptly repaired the 
patient recovers and remains in excellent health. If, 
however, they are not repaired, the patient may suffer 
indefinitely as a result. We have already warned nurses 
not to assume the responsibility of stating that a lacera- 
tion is or is not present. The physician must examine 
the patient himself to ascertain this point. 

The Operation. — Instruments for the repair of lacer- 
ations, with suture material, should be steriHzed and kept 
in readiness for each case of labor. The repair of lacera- 
tions is usually done as soon as possible after the 
birth of the child. In some stitches are inserted before 
the placenta is expelled, although in most cases the 
physician delays until the womb is completely emptied. 
If the operation will be long and painful, ether is given 
if the patient is in good condition. If the physician 
does not wish to give an anesthetic because of the feeble 
condition of the patient, it may be omitted. The patient 
is placed upon her back at the edge of the bed or 
table, and her limbs supported by a sheet, as already 
described in speaking of the use of the forceps. If 
possible, a Kelly pad should be employed, and a rubber 
sheet should be placed over the edge of the bed and a 
slop-jar beneath the rubber sheet. The physician will 
require an antiseptic solution in a sterile basin, with 
sponges of gauze, his instruments within convenient 
reach, a plentiful supply of hot water, and an antiseptic 
solution of the strength desired for a vaginal douche if 
necessary. The nurse's duties during the operation con- 
sist in preparing her hands suitably, supplying sponges 
and antiseptic fluid to keep the parts clean, in threading 
needles as required and assisting the anesthetizer, and in 



CARE OF STITCHES, - 15I 

having ready clean dressings to use after the operation 
is completed. 

Care of Stitches. — The care of the stitches after the 
closure of the laceration is an important matter. Unfor- 
tunately, the genital tract is not like the skin in an ab- 
dominal incision. It cannot be protected by a heavy 
antiseptic dressing, nor can the parts be closed up abso- 
lutely, because they are likely to be soiled by discharges 
from the bowels and bladder. Stitches must be cleansed 
at regular intervals with such material as the obstetrician 
may direct. Care must be taken that the stitches do not 
become infected, and thorough surgical cleanliness is 
requisite in looking after them. Unless other directions 
be given, the nurse may cleanse the stitches as follows : 
She should first prepare a basin of antiseptic solution, 
usually mercuric chlorid (i : 8000 to i : 4000). A recep- 
tacle for the soiled dressings should be at hand, and also 
clean dressings for application. Beneath the patient 
should be placed a douche-pan or bed-pan, or a folded 
sheet or towels, to receive antiseptic fluid. The patient's 
Hmbs should be separated and wrapped with sheets or 
blankets. The nurse should cleanse her hands by scrub- 
bing them with soap and water, then rinsing them and 
scrubbing in water only, and then in mercuric chlorid 
solution (i : 2000). Having prepared a basin of anti- 
septic fluid containing sponges of gauze or sterile cotton, 
she should first allow the antiseptic fluid to flush the 
parts very freely, holding a handful of gauze or cotton 
from the basin above the parts. Should there be secre- 
tions or discharges present, these should be carefully 
wiped off with the gauze and the parts made clean. Dip- 
ping the left hand then into the bichlorid solution, she 
should separate the labia with the thumb and fingers, 
and then flush off the tissues again with gauze held in the 



152 OBSTETRIC SURGERY, 

right hand. The fluid should be allowed to fall into the 
vagina, and thus the stitches will be thoroughly flushed. 
The nurse should not rub the stitches nor pull upon 
them, and under no circumstances should she insert her 
finger or any instrument within the vagina without the 
doctor's orders. Antiseptic fluid may be poured upon 
stitches from a small pitcher ; this method is especially 
useful to nurses when stitches are deep in the pelvic 
floor. When the parts have been flushed clean, a fresh 
dressing should be applied. In some cases the physician 
will order an antiseptic powder to be sprinkled into the 
vagina after the cleansing. 

Douches. — Vaginal douches are sometimes given to 
cleanse stitches during the lying-in period. The douche- 
tube should be boiled before using, and the antiseptic 
solution made in accordance with the doctor's orders. 
The external parts should be cleansed with an antiseptic 
solution. The nurse's hands must be made aseptic, and 
the douche-tube introduced after the fluid has begun to 
run. The douche-bag should not be more than three or 
four feet above the patient. Care should be taken that 
the douche-tube is removed from the vagina before all 
of the fluid has escaped. When not in use the douche- 
tube should be kept in a solution of some antiseptic fluid 
as the doctor may order. 

Removal of Stitches. — Stitches are usually removed 
about ten days after their insertion. The nurse should 
have the patient lie upon her back at the edge of the bed 
or table, her limbs suitably protected and placed on chairs. 
A basin of antiseptic fluid with gauze or cotton sponges 
should be ready. The external parts should be cleansed 
as if the patient were about to receive a douche. The 
instruments of the obstetrician should be boiled and his 
hands made aseptic. A good light should be available, 



INTRA-UTERINE DOUCHING. I 53 

and a candle is often useful. After the stitches have 
been removed the perineum is cleansed with an antiseptic 
solution and a clean dressing is applied. 

Complications with Stitches. — Cases are occasionally 
seen in which the patient during the lying-in period com- 
plains of much irritation about the stitches. This some- 
times arises from the fact that the stitches catch in the 
dressing, and when the patient moves a pull is made 
upon the stitch, which is painful. It is sometimes useful 
in these cases to apply sterile glycerin to the tissues in 
which the stitch is embedded. This may be done under 
antiseptic precautions. If, when the nurse cleanses the 
stitches, she sees pus forming about them, she must notify 
the physician as soon as possible. Should the parts be 
very red and very much swollen, she should also notify 
him. If the stitch begins to cut into the surrounding 
tissues, it is an indication that the time for its removal has 
come, and the doctor must be informed of the fact. 
There are several ways of arranging stitches so as to 
give the least irritation afterward. By one method the 
ends of the stitches are left and gathered into a knot 
at the end of the group ; they are then carried upward 
at one side and the dressing is applied from below upward. 
By still another method the stitches are tied together and 
carried upward and backward into the vagina. In other 
cases the stitches are cut short. Catgut and silk stitches 
give the least discomfort . afterward, while silkworm-gut 
stitches are sometimes annoying. 

OBSTETRIC OPERATIONS IN SEPTIC CASES. 

Intra-uterine Douching. — When septic infection 
develops interference must be practised as soon as possible. 



154 OBSTETRIC SURGERY. 

The washing out of the uterus with either a douche-tube 
or a curet is usually necessary. This must be done 
under antiseptic precautions, the tube and instruments 
first thoroughly boiled, and the patient's tissues made as 
aseptic as possible before the operation. The patient is 
placed in the dorsal position and is prepared as for any 
other vaginal operation. Antiseptic precautions are taken 
by the physician and nurse ; an anesthetic is often given, 
although omitted in some cases. Under a good hght the 
physician will usually inspect the parts, and then, dilating 
the uterus if needed, he will introduce a douche-tube or 
curet and thoroughly wash out the interior of the womb. 
Unless bleeding occurs nothing will be placed within the 
womb. In some cases the uterus is tamponed with iodo- 
form gauze. If ulcers are found in the vagina or pelvic 
floor, strong antiseptic solutions are applied to them. 
Iodoform is often sprinkled very plentifully upon the tis- 
sues. The washing out or curetting of the uterus is not 
frequently repeated. If thoroughly done, once or twice 
is usually sufficient. 

Hysterectomy. — Should the womb become exten- 
sively diseased the obstetrician may perform hysterectomy, 
either complete or partial. The preparations for the 
operation are made as in Cesarean cases. The manage- 
ment and after-treatment of these patients are the same 
as those described. 

Draining" Abscesses. — In septic cases abscesses 
sometimes form in the pelvis or in the abdomen. These 
may be opened through the vagina or by making an 
incision in the abdominal wall. The usual precautions 
taken in surgery for the treatment of such cases must be 
employed. Where inflammation of the breast occurs 
with abscess, opening and draining the abscess, thorough 



IXSTRUMEXTS. 




Fig. 39- — Davis's intra-uterine douche. 




Fig. 42. — Pratt's uterine 
dilator. 



Fig. 43. — Goodell's uterine 
dilator. 



156 



OBSTETRIC SURGERY. 




Fig. 44. — Pean's Fig. 45. — Kelly's 
curved hysterec- hysterectomy 

tomy forceps. needle. 



Fig. 46. — Smith's 
wire eraseur. 



Fig. 47. — Koeberle's 
serrenoeud. 



cleansing or curetting the tissues, and applying proper 
dressings must be practised. The nurse's duties for such 
an operation would be those similar to any surgical pro- 
cedure. 



OPERATIONS ON THE WOMB. . 157 

PLASTIC SURGERY. 

Injuries to the cervix, vagina, pelvic floor, and rectum 
received during labor frequently require repair some time 
after the birth of the child. These cases naturally come 
to the obstetrician for reHef, as his constant observation 
of parturient women enables him to appreciate the injury 
and to remedy it in the best possible manner. 

Operations on the Womb. — In many of these 
cases the womb is found too large and heavy, having 
never contracted properly after the birth of the child. 
In some of these patients the cervix has been torn and 
has never properly healed. In addition, an unhealthy 
state of the lining membrane of the womb is present. 
These cases require curetting, with repair or removal of 
the torn cervix. 

Preparation of the Patient. — The patient should have a 
few days' rest in bed, so that the intestine can be thoroughly 
and efficiently emptied as ordered by the physician. A 
specimen of urine should be sent to the physician for 
examination, and the patient should take water freely to 
bring the kidneys into good working order. The skin 
should be cleansed by repeated bathing, with light mas- 
sage. If the patient complains of any symptom or 
gives a history indicating a condition which might 
render anesthesia dangerous, this fact should be re- 
ported at once to the physician in charge. 

Disinfection of the Vagina and Cervix. — To disinfect 
the birth-canal thoroughly, the nurse should trim the 
hair from the parts, or, if the physician desires it, the 
parts should be shaved. The vaginal mucous membrane 
should be thoroughly scrubbed with sterile cotton dipped 



158 OBSTETRIC SURGERY. 

in green soap or in tincture of green soap, as the physi- 
cian may order. Nurses must understand clearly the 
difference between green soap and tincture of green soap. 
Green soap is a dark brownish soft soap, resembling 
very much the soft soap made for domestic use by 
domestic methods. Tincture of green soap is green soap 
dissolved in alcohol. The first is a pasty solid; the 
second, a liquid. Some physicians prefer to use the soap; 
others, to use the tincture. To perform this scrubbing of 
the mucous membrane, the nurse should thoroughly dis- 
infect and antisepticize her hands and wear sterile gloves ; 
prepare the dressing-forceps and pledgets of cotton or 
sterile gauze ; and the external parts should be thoroughly 
scrubbed with tincture of green soap and water or green 
soap and water. Introducing two fingers of the left hand, 
the nurse should depress the posterior wall of the vagina, 
thus opening the canal. Taking a ball of cotton or of 
gauze with the dressing-forceps, and clamping the dress- 
ing-forceps upon it, the nurse should dip it in the soap 
mixture, insert it in the vagina and thoroughly but gently 
rub the walls of this canal. She should carry the cleans- 
ing well up to the cervix, but should not thrust the 
gauze or cotton into the cervix. If this is done gently 
but firmly, it will not produce pain. This should be 
followed by a copious warm douche of sterile water, 
and after this an antiseptic douche ordered by the physi- 
cian. Many obstetricians use mercuric-chlorid solution 
(i : 20CXd), while others employ lysol (i or 2 per cent.). 
Some prefer to combine lysol with the soap used in 
the scrubbing. After the vagina has been thoroughly 
douched a copious dressing of sterile gauze or antiseptic 
gauze is placed over the vulva. 

Disinfection of the Cervix. — In many of these cases the 



OPERATIONS ON THE WOMB. 1 59 

cervix contains an unhealthy secretion of muco-pus. This 
must be removed, and its removal usually requires the 
use of instruments. The physician will in most cases 
perform this manipulation himself He will have the 
patient placed in the dorsal position, and, introducing a 
sterile speculum, he will swab out the cervix with soap, 
followed by water, and then by an antiseptic solution. 
Experienced nurses are sometimes requested by physi- 
cians to do this for them. 

Preparation of the Rectimi. — For such an operation the 
rectum must be thoroughly emptied by purgatives and 
enemas, and just before the operation should be copiously 
douched with sterile water or salt solution, as the physi- 
cian may direct. 

Catheterizhig. — Nurses must remember that under the 
nervous excitement of anesthesia a patient may secrete a 
considerable quantity of urine. Accordingly the patient 
should be catheterized just before the operation begins. 
The tissues about the meatus should be thoroughly 
cleansed with bichlorid solution (1:2000), the catheter 
should have been boiled, and the nurse's hands thoroughly 
disinfected. After the urine has been removed the tissues 
about the meatus should again be cleansed with bichlorid 
solution. 

Posture of the Patient; Table ; Appliances. — Plastic 
operations upon the womb are performed with the patient 
in the dorsal or in Sims's position (Fig. 48). The nurse 
should prepare or improvise a table as the physician 
orders. It is especially necessary in these operations 
that a good light be available, as it is sometimes difficult 
to illuminate properly the field of operation. The nurse 
should have in readiness an abundance of hot water and the 
antiseptic solutions prescribed by the doctor. The Hmbs 



i6o 



OBSTETRIC SURGERY. 



of the patient must be supported in such a manner as to 
open the birth-canal widely, and not to be in the way 
of the operator. Stirrups or the sheet-sling are usually 
efficient for this purpose. As the nurse will be required 
to assist with instruments or sutures, the legs must be 
supported without her help. Antiseptic gauze and cot- 




FiG. 48. — The Sims position. 



ton, antiseptic vulvar dressings, and sterile T-bandages 
should also be ready. 

histriune7its and Siiturcs. — The physician's instruments 
and gloves are sterilized by boiling, and placed con- 
veniently in a sterilizer or clean basin. It is well, if pos- 
sible, to separate the needles and sutures from other 
instruments, to facilitate the work of the operator. As the 
nurse will usually thread the needles, she should know 
something of the sorts of suture employed. Medium-sized 
silk, silkworm-gut, chromicized catgut, and silver wire may 
be used. Some catgut is furnished in sterile, hermetically 



OPERATIONS ON THE WOMB. l6l 

sealed tubes, which must be broken to extract the suture. 
These tubes are marked by a file at the point where force 
should be exerted. If the nurse will take the tube in 
the two hands, wrapped in a sterile towel, and bend the 
tube sharply, making pressure at the filed point, the tube 
will usually break without difficulty. The catgut wound 
upon a small rod is then readily removed. If silver wire 
be employed, perforated shot are usually necessary for 
clamping the wire. The needles used in these operations 
are curved, sharply pointed, and very strong. 

Dressings. — There is usually no dressing applied di- 
rectly to the cervix in these cases. The vulva is covered 
with an antiseptic gauze dressing retained by a T-bandage. 

Douches. — In many cases the physician will order 
douches for these patients during convalescence. These 
are antiseptic solutions, and should be given with a 
sterilized glass douche-tube under strict antiseptic pre- 
cautions. Some physicians require the patient to be 
catheterized after an operation upon the cervix, while 
others do not. 

Taking out Stitches. — The removal of stitches from the 
cer\dx is sometimes attended with considerable difficulty. 
The patient must be put in the dorsal or in Sims's posi- 
tion, and a good light is absolutely essential. The physi- 
cian's instruments must be sterilized by boiling, and a 
vaginal douche is usually ordered before and after taking 
out the stitches. The physician will arrange the patient 
in such a posture that the light will be best. He will 
then introduce the speculum or other instruments, and 
may request the nurse to hold them in exactly the posi- 
tion in which he has placed them. She must be careful 
to do this as accurately as possible. The stitches are 
then grasped with forceps, gentle traction made upon 



1 62 OBSTETRIC SURGERY. 

them, the loop cut, and the stitch removed. Nurses 
must be careful not to throw away stitches until they 
are sure that the doctor does not wish to inspect them. 
It is important that no part of a stitch be left behind, 
and to be sure that this has been avoided it is custo- 
mary to count and examine the stitches after their 
removal. 

I/ate or Secondary Operations for I^aceration 
of the Vagina, Pelvic Floor, and Perineum. — 
Preparation of the Patient. — These cases are prepared 
for operation in the manner already described. If the 
laceration is extensive, several days may be required thor- 
oughly to empty the bowel. The patient must be put 
upon liquid diet, and purgatives and laxatives employed 
freely, with copious enemas. In some cases it is neces- 
sary to restrain the bowel movements for several days 
after the operation, and the bowels must be thoroughly 
emptied to make this possible. 

Disinfection of the Vagina and Rectum. — Especial at- 
tention is given in these cases to disinfecting the vagina 
and rectum. The hair should be removed from the parts, 
as already described, the scrubbing of the vagina must 
be done very thoroughly, and in many cases an antiseptic 
soap or antiseptic mixture will be ordered. Copious 
douches of sterile water should be given after scrubbing, 
followed by antiseptic douches. If the patient is allowed 
to empty the bladder spontaneously, the tissues about 
the meatus should be cleansed after each urination. In 
many cases the physician orders the patient to be cathe- 
terized. In disinfecting the rectum difficulty is some- 
times experienced because of the irritability of the 
sphincter muscle. This can usually be overcome by 
gently but firmly stretching the muscle. The nurse 



LATE OR SECONDARY OPERATIONS. 1 63 

may insert the finger, anointed with some lubricant, 
and, making gentle traction around the muscle, may 
overcome to some extent the irritability which is present. 
In some patients hemorrhoids interfere considerably with 
the preparation of the patient, and increase very much 
her discomfort. The rectum should be cleansed by copi- 
ous douching with green soapsuds, or a mixture of tinct- 
ure of green soap and water, followed by the free use of 
sterile water, and then by an antiseptic solution. Many 
physicians employ normal salt solution extensively in 
these cases. The rectum should be washed out just 
before the operation, after the patient is anesthetized. In 
many cases, as the patient relaxes under anesthesia, fecal 
matter which has been retained by the intestine comes 
down into the rectum, and the nurse is much annoyed 
by having the patient's bowels move at this inconvenient 
time. Accordingly, after the patient is completely anes- 
thetized it is usually wise to douche the rectum thor- 
oughly before the operation commences. 

Table and Appliances. — Operations upon the vagina, 
pelvic floor, and rectum are almost invariably done 
with the patient in the dorsal position. Many operating- 
tables are available, with convenient appliances for hold- 
ing the limbs (Fig. 49). If the nurse must improvise a 
table, it should be of good height, not too wide, firm, 
and not too large. It should be covered with a folded 
blanket and sheet, and over this at the foot of the table 
should be placed a Kelly pad or an improvised pad made 
of rubber sheeting. As fluid is freely used during these 
operations, it is essential that the nurse so arrange the 
patient that very free return flow can be procured. A 
rubber pad is almost indispensable for this work. Some 
physicians use in this operation marine sponges. Most, 
however, use pledgets ^ sterile cotton or sterile gauze. 



164 



OBSTETRIC SURGERY. 



They should be prepared in abundance. It is very essen- 
tial that a free supply of sterile hot water be at hand for 
this operation. Many obstetricians practise continuous 

irrigation of the field of 
operation with hot sterile 
^ water, and it is evident that 
there should be an abun- 
dant supply. A fountain- 
syringe should be hung 
within convenient reach ; 
and if continuous irrigation 
is to be performed the 
nurse must obtain from the 
physician or by his order 
such a tube as he desires. 
If no especial tube is avail- 
able, the largest size medi- 
cine-dropper maybe taken, 
its rubber portion removed, 

Fig 49-Woman in the dorsal position with ^^^^ ^j^^ j^ ^^^^ ^^ ^^^ 

feet supported in Edebohls stirrups. <=> 

glass portion inserted into 
the tube of a fountain-syringe. This simple appliance 
has proved very convenient. As the legs of the patient 
must be kept in position for some time, the nurse should 
see that suitable and comfortable appliances are at hand 
for this purpose. It is much better to take a little time 
at the beginning of the operation and have the patient in 
perfectly good position, than to have the operation inter- 
rupted afterward by the necessity for change. Hot water 
is sometimes required to check oozing during these oper- 
ations. Water at a temperature of 100° to 1 10° F. must 
be in readiness. Solutions employed are sterile salt solu- 
tion and dilute antiseptic solutions. 

histniments and Sutures. — The physician's instruments 




LATE OR SECONDARY OPERATIONS. 



165 



will consist of a scalpel, scissors, dissecting-forceps, tenac- 
ulum-forceps, hemostatic forceps, and uterine dressing- 
forceps. If silver wire be employed with shot, a shot- 
crusher is necessary. Suture 
material employed is silk, silk- 
worm-gut, chromicized catgut, 
kangaroo-tendon, or silver wire. 
A sufficient number of needles 
must be provided so that the 
obstetrician shall not be de- 
layed by time lost in having 
needles threaded. 

Posture of the Patient. — This 
is usually the dorsal position, 
occasionally Sims's. In cases 
of opening or fistula between 
the bladder and vagina the 
patient may be put for a time 
in a modified knee-chest pos- 
ture. It is very important that 
she be put in exactly the posi- 
tion desired after she is anes- 
thetized, and it is better to wait 
until the patient is relaxed be- 
fore attempting to place her in 
position. Most operators pre- 
fer to employ stirrups or leg- 
holders, while some prefer that 
the patient's limbs be held by nurses and assistants. 

Dressings. — Sterile or antiseptic gauze in strips two 
inches wide should be prepared. Sterilized or antiseptic 
gauze with sterile or borated cotton should be in readi- 
ness for the preparation of vulvar dressings. T-bandages 
are used in these cases. 




Fig. 50. — Shot compressing 
forceps. 



1 66 OBSTETRIC SURGERY. 

Duties of the Nurse during the Operation. — During 
this operation the nurse may be required to direct the 
stream of water upon the parts, to hold instruments, 
thread needles, hand sponges, or in some cases to sponge. 
She should be especially careful to maintain an aseptic 
condition of her hands, using sterile gloves, and to be 
sure that the dressings, instruments, and appliances which 
she prepares are clean and sterile. 

The Care of the Stitches. — Many obstetricians have no 
douches given after plastic operations. The patient, how- 
ever, is catheterized under strict antiseptic precautions, 
and the parts are carefully protected by a large vulvar 
dressing of antiseptic gauze and cotton. Other operators 
prefer the use of vaginal douches given under strict anti- 
septic precautions. 

The Bowels. — Where there has been a very extensive 
tear of the vagina and rectum the obstetrician may give 
opium to prevent a movement of the bowels for several 
days after the operation. In administering this drug, the 
nurse must be careful to follow the dose and interval ex- 
actly, and to note the development of the constitutional 
effects of opium. It is usually given by suppository, by 
hypodermic injection, and occasionally by the mouth. 
When the laceration has not opened the bowel widely the 
physician will usually order the bowels moved on the 
second or third day after the operation. Laxative medi- 
cines followed by enemas are ordered. Where the lacera- 
tion has been extensive the bowels may not move for five 
or six days after operation. When this must be done the 
physician will prescribe laxative medicine and enemas. 
The nurse should watch to detect any symptom of desire 
on the part of the patient for a movement of the bowel. 
It is often customary when such occurs to inject into the 



LATE OR SECONDARY OPERATIONS. 1 67 

bowel from two to six ounces of sterile olive oil, making 
the injection very gently and having the oil warmed to 
98° F. The patient is encouraged not to strain, and to 
retain the oil if possible. When the patient feels that the 
bowel movement is inevitable, an enema of simple warm 
water or of soapsuds and water is given. In giving the 
enema, a rubber catheter, not too large, should be used and 
great care taken in passing it, that no harm be done the 
stitches. After the bowels have moved, the nurse should 
wash out the rectum with sterile water or normal salt solu- 
tion, and cleanse the parts thoroughly with antiseptic solu- 
tions, and, if the doctor orders, should give a vaginal anti- 
septic douche. She should report at once to the doctor any 
signs that fluid from the bowel has passed through into the 
vagina. This may happen for a few days after the move- 
ment of the bowels, but if the vagina and rectum be kept 
thoroughly clean the parts usually close without further 
complication. Should the bowels become distended with 
gas at any time, and the patient threaten to strain and 
bear down, the nurse may very gently pass a rectal tube, 
allowing the gas to escape. 

Prevention of Tearing the Stitches. — When the patient 
recovers from the anesthetic she may become greatly 
excited, and be seized with a strong desire to bear down 
and have the bowels move. If this be not controlled, the 
patient may tear asunder some of the stitches and ruin 
the result of the operation. It is customary for physi- 
cians to instruct the nurse to use opium to control such 
cases. The nurse should give the hypodermic injection 
or the rectal suppository when such symptoms appear. 
She can do much to control the patient by gentleness, by 
flexing the thighs upon the trunk, by turning the patient 
on the left side, and by encouraging her not to yield to 
pain or disagreeable sensations. 



1 68 OBSTETRIC SURGERY. 

Removing the Stitches. — The stitches are usually re- 
moved in from ten days to two weeks after the operation. 
Chromicized catgut usually remains in place from ten to 
twenty days, the knots finally coming away with a 
douche or dressing. Should soreness, redness, and pus 
appear between the stitches, the nurse must notify the 
physician at once. If soreness only be present, the ap- 
plication of sterile glycerin, made with sterile gauze or 
cotton, to the tissues about the stitches will often be 
followed by relief For the removal of the stitches the 
physician will usually place the patient in the dorsal 
position, her limbs supported properly, and instruments 
and antiseptic solutions available. A good light should 
be obtained. After the removal of the stitches a vaginal 
antiseptic douche is often given. 

Convalescence of the Patient. — During her convales- 
cence the patient must be catheterized, or may pass her 
urine as the physician orders. It is usually necessary to 
employ enemas for some time. It is rarely needed to 
bind together the patient's limbs, although this is occa- 
sionally done. Especial care must be taken that the 
patient does not get up and about too soon, and that she 
does not have a hard and constipated bowel movement, 
causing her to strain freely. A slight mucous discharge 
persists for some time after these operations in many 
cases, but a purulent discharge should not occur, and 
would indicate that infection had arisen. Nurses must 
not understand that septic infection may not arise in 
operations which do not open the peritoneum. Although 
most plastic operations are done successfully in good 
hands, it is possible for fatal infection to arise during or 
after one of these operations, with the usual symptoms of 
blood-poisoning. The nurse cannot be too careful or par- 
ticular in her antisepsis and in the aseptic care of herself. 



CHAPTER XI. 
NURSING IN PUERPERAL SEPSIS. 

In almost all cases puerperal septic infection can be 
prevented, and this occurrence must be looked upon in 
most cases as resulting from some omission or wrong- 
doing of those who care for the patient. When it does 
occur it is very important that the patient be properly 
cared for, as her recovery will depend very much upon 
the nursing which she receives. 

The prevention of puerperal sepsis requires the 
strict observance of those antiseptic precautions invariably 
practised by careful surgeons. TJie nurse sJwiild consider 
each pregnant and parturient patient as a surgical patient, 
and, so far as antiseptic precautions are concerned, an 
abortion or labor must be treated as a surgical operation. 
By this we mean that in attending a case of abortion or 
labor the nurse must exercise strict antiseptic precautions 
regarding herself, the instruments, appliances, dressings, 
and the external genital organs of the patient. She 
should not insert her finger or an instrument within the 
genital tract of the patient without the consent of the 
obstetrician, for the same reasons which would prevent 
her from inserting her finger into a wound or into the 
abdominal cavity during an operation. 

Symptoms. — The symptoms of puerperal sepsis are 
fever, with tenderness in the abdomen, a large, soft womb, 
and usually an altered condition of the lochial discharge. 

169 



170 NURSING IN PUERPERAL SEPSIS. 

In sepsis the patient has been attacked by germs which 
will destroy her blood and exhaust her vitality unless she 
can resist them. In this contest she requires all the as- 
sistance which proper nourishment, stimulus, and surgical 
help can give her. Puerperal sepsis sometimes begins 
with chill. At other times the temperature rises steadily 
from the first to the third or fourth day. The palse is 
rapid, and there is usually constipation or diarrhea. 

The nurse must report to the attending physician a 
chill, rise of temperature, or a rise of the pulse-rate of 
the patient. Nurses must not be deceived by a slight 
sensation of chilliness which is often felt immediately 
after labor. This is very different from the distinct rigor 
characteristic of puerperal sepsis. 

Cleansing the Birth-canal. — When the physician 
sees his patient he will usually find it necessaiy to 
examine not only the external surface of the body, but 
also the condition of the genital tract. The nurse must 
prepare an antiseptic solution, plenty of hot water and 
dressings, and place the patient on her back across the 
bed for a bimanual examination. It is usual to wash out 
the birth-canal as thoroughly as possible either before or 
after such an examination. The nurse must have ready 
the appliances and solution for a douche ; and if an intra- 
uterine douche be given there will be needed normal salt 
solution or an abundance of hot sterile water. After the 
examination vaginal douches may be ordered at regular 
intervals. These must be given with the antiseptic pre- 
cautions already described. It is not customary for 
nurses to give intra-uterine douches, and the nurse should 
decline to assume so responsible a task. 

Purgatives ; Counter-irritation. — The patient will 
usually be ordered purgative medicines and glycerin and 



TREATMENT OF FEVER. 171 

saline enemas. The diet will be liquid ; and if there is 
much pain in the abdomen the nurse may be ordered to 
place upon the abdomen a turpentine stupe, with or with- 
out an ice-bag. In some cases hot applications are made. 
To prepare a turpentine stupe for such a case, a piece of 
flannel is selected large enough to cover the abdomen from 
the pubes to the epigastrium. This should be folded in 
two thicknesses, and should be wrung out of one pint 
of water to which has been added one tablespoonful of 
spirits of turpentine. This is then laid smoothly upon 
the abdomen, and over it is placed one thickness of thin 
flannel, and upon this an ice-bag or hot-water bag. The 
choice is left to the attending physician. Such an appli- 
cation is clean, easily renewed, does not blister if carefully 
watched, and relieves pain in most cases. If the action 
of the turpentine is not well borne, it may be removed 
and the ice-bag or hot-water bag be used alone. 

Treatment of Fever. — For the reduction of fever 
in septic cases cold is commonly employed. Cold 
sponging and the use of the ice-bag or of the cold 
pack are the methods generally used. The cold sponge 
is usually more effectual if a tablespoonful of alcohol be 
added to the pint of cold water. If the patient sweats 
freely, a little ammonia may also be added. With some 
patients the use of cold does not agree, and considerable 
depression and shock follow a cold bath or pack. In 
these cases good results are obtained by sponging the 
patient with hot water to which ammonia or alcohol has 
been added. When the temperature is high and the 
patient sweats profusely, she will usually not be able to 
take food during the highest fever. If the temperature 
be reduced, she can, however, retain and assimilate Hquid 
food. The nurse must watch her opportunity in these 
cases to feed and stimulate the patient when the tempera- 



172 NURSING IN PUERPERAL SEPSIS. 

ture has been reduced by sponging or packing. In some 
cases friction with ice, as sometimes employed in typhoid 
or sunstroke, will be found advantageous. 

Nourislimetlt. — The question of feeding in these 
cases is of the utmost importance. Milk must usually 
be peptonized to be readily absorbed. Rapid peptoniza- 
tion by the cold process gives the best results. Milk- 
foods, such as junket, koumiss, buttermilk, and custards, 
should be used freely. Broths and soups, beef-juice, 
white-of-egg water, raw eggs beaten up with whiskey or 
sherry, are also needed. If fever be very high and thirst 
great, small quantities of cool drinks at frequent intervals 
are required. The best and simplest ice-cream and ices 
are occasionally useful if taken partially melted. The 
nurse must employ every expedient to secure the taking 
of food. The patient should not be asked what she de- 
sires, but nourishment should be brought to her at favor- 
able intervals and without delay and argument. It is 
most important that these patients should take a con- 
siderable quantity of pure water. If this is given in 
small quantities frequently, it will not distress the stomach, 
but prove most comforting to the patient. Iced water 
should not be used, but that which is pleasantly cool 
should be selected. Aerated water, very weak lemonade 
without sugar, or cream of tartar lemonade, are useful. 

Stimulation. — The use of alcoholic stimulants is 
very important in septic cases. Wines are seldom em- 
ployed extensively, as they are rarely pure and often 
disturb digestion. The best quality of whiskey and 
brandy is usually employed. A thoroughly septic patient 
will often consume enormous quantities of alcoholic 
stimulants without the least sign of intoxication. Stimu- 
lants may usually be given with water, and as a beverage 
to quench thirst. Better results are obtained in the long 



BED-SOjRES. 173 

run by giving food and stimulants separately than by 
combining alcohol with articles of diet. In addition to 
alcoholic stimulants the nurse may be ordered to ad- 
minister tonic and stimulating medicines, occasionally by 
hypodermic injection. 

Operations. — Operative treatment may become neces- 
sary during puerperal sepsis. Washing out of the womb, 
curetting the uterus, incision into the vagina or into the 
abdomen to empty an abscess, or abdominal section fol- 
lowed by the removal of diseased organs may be per- 
formed. The nurse must prepare for these operations as 
is usually done. The preparation for Cesarean section 
already given may be followed if other orders are not 
received. Septic patients are often annoyed by diarrhea. 
The discharges may be irritating in charadter. Unless 
the patient be well cared for, much suffering and the for- 
mation of a bed-sore may occur. Strict cleanliness, with 
frequent changing of the dressing and the use of healing 
ointments, will keep the patient in good condition. 

Bed-sores. — In some cases bed-sores form very 
easily. Bathing with alcohol or alcohol and alum, the 
use of rubber adhesive plaster, the use of ice, and turn- 
ing the patient frequently upon the side may all be em- 
ployed. With some patients, lying directly upon a 
blanket is one of the best preventives of bed-sore. The 
use of rubber rings or sheeting is objectionable because 
of its heating and irritating properties. It is better to 
use ample dressings and little rubber material about the 
patient. Ointments are often of value. The mixture 
known as Hornor's ointment is an excellent one ; it is 
composed of equal parts of alcohol and castor oil, with 
sufficient powdered oxide of zinc to make a paste. The 
mattress used in puerperal septic infection should be 
burned at the termination of the case. 



174 NURSING IN PUERPERAL SEPSIS. 

The Nurse. — A most important matter in this con- 
nection is the care which the nurse must take of herself. 
A scratch, a cut, or a neglected hang-nail on her hands 
may result in infection, in serious illness, or death. The 
constant demand upon her strength and the anxious and 
depressing nature of the case make such patients difficult 
to attend. It is necessary to wean the child, and this 
adds to the nurse's cares. She must be very cautious in 
the care of her hands, and rubber gloves or rubber fin- 
gers are excellent in dressing a septic patient. The use 
of a healing lotion or ointment, appHed upon the hands 
and around the nails before retiring, will prove of great 
value. She must be careful to take a regular allowance 
of fresh air and sleep, and to maintain her nutrition in 
every possible way. She must be very careful regard- 
ing the avoidance of infection in the eyes. Antiseptic 
solutions sometimes spatter into the eyes, setting up 
severe irritation. Septic fluids may also gain access to 
the eyes. The nurse must not rub her eyes while 
attending a septic case. Should smarting and redness 
occur, she should consult an ophthalmologist at once. 

On leaving the case the nurse must spend at least a 
week in disinfecting her clothing and belongings and in 
cleansing her own body. The hair must be thoroughly 
washed not only in the usual manner, but also with 
bichlorid of mercury solution 1:4000 or carbolic acid 
solution, I per cent. Repeated baths should be taken, 
and, ig addition, an antiseptic bath of bichlorid i : 4000, 
or I per cent, carbolic acid. The throat and eyes should 
be especially examined to determine the presence of 
infection. If possible, the nurse should not take an 
obstetric or surgical case for a month. She should be 
as much as possible in the open air, and exercise the 
utmost caution to secure cleanliness. 



NURSING THE CHILD. 1/5 

Nursing the Child. — Puerperal septic infection 
usually makes it necessary to stop the mother's nurs- 
ing. The breasts may become infected and abscess of 
the breast be added to other compHcations. The child 
must be fed at regular intervals with food prepared by 
the doctor's written orders. Care must be taken that the 
child does not become infected at the umbilicus or in the 
eyes or mouth. It is better that the child should be with 
the mother as little as possible in such a case. 

Such patients require two or more nurses. It is im- 
possible for one nurse to give mother and child proper 
treatment without sacrificing their good and her own 
health. The case is so serious and so much depends 
upon the patient's nursing that two or more nurses 
should be in attendance. The physician must decide 
whether one nurse shall take exclusive care of the 
mother and the other of the child, or whether they 
shall alternate. It is usually better to have one nurse 
to do the surgical dressing for the mother, and the 
other nurse to dress the umbilicus and bathe the child. 



CHAPTER XII. 

COMPLICATIONS OF THE LYING-IN PERIOD. 

COMPLICATIONS WITH THE BREASTS. 

Excess of Milk. — The flow of milk may be exces- 
sive or deficient. In the first instance the patient is an- 
noyed by having her clothing and the bed soiled by the 
constant leaking of milk. To prevent this the nurse 
should keep the breasts abundantly covered with sterile 
gauze, which will soak up the excess, and the patient's 
diet will be altered as the physician shall direct. It is 
usual in these cases to withhold Hquids, cereal foods, 
cocoa, and some of the vegetables, and to give the patient 
a diet poor in liquids, in starches, and in sweets. The 
most strict cleanliness must be observed in these cases, 
to avoid the retention and decomposition of milk in the 
clothing or upon the body. The supply usually dimin- 
ishes when the patient gets up and is able to be about. 

lyack of Milk. — Too little milk may be the result of 
lack of physical development or vigor in the mother, or 
may be caused by depressing mental influences or by im- 
proper diet. Worry will produce almost entire cessation 
of the secretion of milk, and. great and sudden mental 
shock often produces the same result. Hence the nurse 
must be careful not to depress the mind of a nursing 
patient, but to encourage and comfort her in every way 
in her power. When the secretion of milk is deficient 
the nurse can assist it by massaging the breast, by fol- 
lowing strictly the diet ordered by the doctor, by encour- 
aging the patient, and by causing the child to nurse at 
regular intervals and as completely as possible. If the 
176 



DISTENTION OF THE BREASTS. 1 77 

patient be encouraged to believe that the secretion of 
milk will not fail, much will be done to help to bring 
about the desired result. 

Abnormal conditions in the breast often arise which 
require careful attention to prevent the development of 
serious mischief. 

Distention of the Breasts. — Caked breasts are 
caused by failure of the milk to escape properly through 
the nipple. Sometimes it seems as if the outer skin of 
the breast is so firm that it will not yield and permit 
the flow of milk. In other cases the breasts are so full 
that it is impossible to obtain milk from them. This con- 
dition is a serious one, because if the accumulation can- 
not be relieved, and should infective bacteria be contained 
in the breast, an abscess will form. The sensible use of the 
breast bandage (Figs. 51, 52) will do much to prevent this 
condition. Massage is an excellent help, and must be 
done by first washing the breast with soap and water and 
making the hands of the nurse aseptic. Having washed 
her hands thoroughly with hot water and soap, the nurse 
should rub the breast gently with the ends of her fingers 
from the outer border of the breast toward the nipple. 
She should raise the breast gently and draw it toward the 
median line at the same time. She may gently knead the 
breast, if the patient experiences no inconvenience during 
the kneading. She should rub lightly with a gentle touch, 
but thoroughly and steadily. The massage maybe con- 
tinued from ten to tw^enty minutes. During the last five or 
ten minutes the nurse should apply to the breast warm ster- 
ile olive oil, rubbing it in thoroughly by the massage. The 
best test of the success of this massage is the relief which 
the patient experiences. Should massage cause acute 
pain, it must be stopped at once. Should the skin over 
the breasts remain brightly reddened after massage, the 
12 



178 COMPLICATIONS OF THE LYING-IN PERIOD. 

treatment must be suspended. Massage should be 
practised just before the regular time for the child to 
nurse. After this, if a breast-pump be cautiously appHed, 
a little milk will be extracted. If then the child is put 
to the breast, it will probably succeed in removing a con- 
siderable quantity of milk. Massage should be practised 
as often as the doctor directs, and is usually done in the 
manner described. Physicians occasionally order hot 
fomentations to be applied just before the child nurses, 
for the relief of caked breast. Gauze or soft flannel may 
be used wrung out of sterile water, and over this oiled 
silk or sheet rubber may be appHed. Fomentations are 
not used so frequently as massage. 

When the breasts are engorged the physician will 
order purgative medicine, and usually salines. This has 
a decided influence in reducing the amount of fluid. The 
diet will also be regulated and confined as much as pos- 
sible to solids. When obstinate engorgement is present, 
with great tension, fomentation should first be applied 
for fifteen to thirty minutes, followed by massage for 
twenty minutes. The child should then nurse. The 
whole proceeding will consume an hour or more. 

Should the mother's milk disagree with the infant after 
fomenting and massage, some milk should be taken from 
the breasts with a pump. This will usually be a yellow 
fluid, containing an excess of fat. This should be dis- 
carded, and the milk which comes after that is suitable 
for the child. If the child can nurse, it may take its food 
after the first milk has been removed by the pump. 

Medicines. — Medicines are sometimes applied directly 
to the breast. Belladonna ointment or plaster, or a 
solution of atropin, as the doctor may direct, may be 
applied upon gauze or lint which has previously been 



V 



' — «-«*(i!i 






Figs. 57-60. — The breasts in pregnancy. Fig. 57. Typical signs iia 
a brunette, including follicles and primary and secondary areolae. FiG. 
58. Elevation of primary areola {E) in profile, compared with an areola 
which is not elevated (composite photograph). Fig. 59. Well-formed, 
firm breast and nipple in a brunette. Fk;. 60. Typical signs in a blonde ? 
F, follicles ; FA, papillie. [American Text- Book of Obstetrics), 



ABNORMAL NIPPLES. 1/9 

Sterilized. Occasionally a physician orders medicine 
administered internally to check the flow of milk. As 
belladonna is the drug usually prescribed, the nurse will 
remember its effects. When the patient is under its 
influence the pupils are dilated, the mouth and throat are 
dry, the pulse is rapid, and the skin is often of a bright 
reddish color. The nurse must report to the doctor any 
signs of the physiologic effects of this drug. 

Abnormal Nipples. — A frequent cause of caked 
breast and abscess is found in diseased or abnormal 
nipples. Such a condition can usually be remedied during 
pregnancy. If not, however, and if the nipple can be 
drawn out sufficiently for the child to grasp it, other con- 
ditions can usually be overcome. To draw out the nip- 
ple, the mouth of the child is undoubtedly the best 
apparatus. Next to this is some form of breast-pump, 
of which there are two. In one the suction is made by 
the expansion of a rubber bulb, and in the other the 
suction is made by the lips of the mother or nurse 
through a piece of rubber tubing. The breast-pump 
should be carefully cleansed after use. Its glass portion 
should be frequently boiled, and when not in use it should 
be kept in a saturated ^solution of boric acid. The 
breast-pump must be used very gently, to prevent bruis- 
ing and injuring the glandular structure. The nipple 
may be drawn out with a heated bottle, by heating the 
bottle in water, emptying it rapidly, inverting it and 
applying it over the nipple. As the bottle cools the nip- 
ple will be drawn through the neck of the bottle. The 
practice of applying the mouth of another person than 
the infant to the breast to draw out the nipple should not 
be encouraged. When the nipples are not only depressed, 
but also deeply inverted, so that cup-like depressions are 



l80 COMPLICATIONS OF THE LYING-IN PERIOD. 

formed, the patient cannot nurse. Great care is requisite 
in keeping these depressions perfectly clean, as milk may 
accumulate and undergo decomposition in them. 

In addition to sunken or depressed nipples, great diffi- 
culty is found when the nipples are so small that the flow 
of milk is very limited. If the child is vigorous and 
hungry, it sucks air into the stomach with the milk, and 
colic and indigestion result. In other cases the covering 
of the nipple is so sensitive that vigorous suction by the 
infant removes the superficial cells and causes the part to 
become sore. In these cases the child must nurse through 
a nipple-shield. Those most usually employed consist 
of a glass bell with a rubber nipple (Fig. 6i). They are 
usually efficient, and the simplest are always to be chosen. 
Nipple-shields are sometimes improvised by taking a bit 
of wax, hollowing it out, and piercing holes through it 
with a large needle. The nipple-shield must be kept 
thoroughly clean by boiling, and when not in use it 
should be kept in a saturated solu- 
tion of boric acid. When the nipples 
are sensitive they must be cleansed 
with the greatest care, as already de- 
scribed, and the physician should be 
requested to prescribe some suitable 
application. Sterile olive oil, an oint- 
ment of lanolin containing boric acid, 
castor oil, and bismuth subnitrate are 
often employed. The physician will 
r.— ippe-s le . somctimcs make applications of an 
astringent or stimulating nature to the nipples. 

Cracks and Fissures in the Nipples. — Cracks 
and fissures may occur, and may be so deep as to cause 
bleeding at the time of nursing. It must be remembered 




BREAST-ABSCESS. l8l 

that in some cases the nipple is fissured congenitally, and 
that the condition is not necessarily one of disease. 
Such cracks or fissures usually divide the nipple into two 
portions, but do not present a sore or wounded surface 
when the child nurses. For cracked or fissured nipple 
strict antiseptic cleansing as described and the use of the 
nipple-shield are usually sufficient The physician must 
always be asked to prescribe an application to be used 
after the child has nursed. We have repeatedly seen 
a cracked and fissured nipple heal and become sound, 
although the child was nursed, under the conscientious 
care of good nurses. If, however, infection occurs, then 
an abscess of the breast usually follows. 

Ulcers on the Nipples. — Nurses should observe 
any sore or ulcerated spot upon the nipples. Syphilitic 
women sometimes have sores upon the nipple, and occa- 
sionally a woman with a tubercular breast has such a 
condition. This must be at once reported to the physi- 
cian, and it will very likely result in stopping the nursing 
of the child. 

Abnormal Milk. — Nurses are sometimes puzzled by 
the appearance of the milk. The first milk obtained 
after the birth of the child may be very yellow and very 
thick. It may almost resemble pus. The attention of 
the physician must always be called to such a condition. 
In other cases a little blood may come with the first 
milk, while in some patients the milk is excessively thin 
and watery and apparently very poor. 

Breast-abscess. — When the patient complains of 
pain in some portion of the breast, and that portion is 
found hard and firm and resisting, and when this does 
not soften with the method of treatment already de- 
scribed, a breast-abscess is threatened. We know that 



1 82 COMPLICATIONS OF THE LYING-IN PERIOD. 

under some conditions, no matter how careful the nurse 
and doctor have been, abscess may occur. Frequently, 
however, we must suspect negligence or carelessness to 
have had something to do with the production of the 
abscess. When pus actually forms the temperature 
rises as high as 103° or 104° F., usually about 102° F. 
The breast is sensitive to pressure, and over the hard 
area a red or pinkish color of the skin is seen. Such 
symptoms must at once be reported to the physician. 

Drainage. — When pus has actually formed the breast 
must be incised and the abscess emptied and drained. 
Some physicians apply hot fomentations to hasten the 
breaking down of the infected material. Others use the 
bandage only, and prefer to incise the breast so soon as 
evidences of infection are positively found. The opera- 
tion of opening and draining the breast should be done 
under ether. The patient is prepared by abstinence from 
solid food and by purgation. The nurse must have 
ready an abundance of hot water, antiseptic solutions, 
one or two half-pound cans of ether, several breast band- 
ages or binders, antiseptic gauze and cotton, and stimu- 
lants. The physician may require drainage-tubing, or he 
may prefer to use gauze as a drain, or to employ strands 
of lint or some other material. The nurse should ask 
what he wishes for this purpose. A rubber sheet will be 
required, and if possible a kidney-shaped pus-basin 
should be employed. An abundance of old linen may 
also be needed. 

Operation. — The breast is prepared for incision by 
washing thoroughly with soap and hot water, then rins- 
ing with hot boiled water, and then washing with mer- 
curic-chlorid solution (i : 2000). The physician's instru- 
ments should have been steriHzed by boiling. A supply 



BREAST-ABSCESS. 1 83 

of sterile towels should be available, on which gauze 
may be cut in convenient strips. The patient's clothing 
should be removed from the chest, and her shoulders 
and the sound breast protected by a soft, thin blanket 
and by clean linen. She usually remains in bed during 
the operation, although in extensive abscess of the breast 
the operator may prefer to place her upon a table. The 
physician will require a syringe for washing out the 
abscess-cavity. A small glass piston-syringe is very 
convenient for this purpose, while some prefer to use a 
fountain-syringe. The nurse must have ready such a 
syringe and solution as may be ordered. 

When the patient is anesthetized and the breast has been 
prepared, the physician will incise the abscess, explore the 
breast thoroughly, and decide whether it is necessary to use 
drainage-tubing or to make other openings. The nurse 
should supply antiseptic solution, gauze or cotton sponges 
wet with an antiseptic solution, and dressings and a 
bandage when the abscess has been emptied. If care be 
taken, the patient's bed need not be soiled ; but without 
this, fluid is very apt to find its way into the center of 
the bed, requiring a complete change. 

These cases need a daily dressing for varying periods, 
and the nurse must have ready the solution and dress- 
ing materials which the doctor may desire. Recovery 
from this condition is often tedious and prolonged, the 
abscess-cavity being slow in closing. In neglected cases 
the abscess may burst spontaneously, or the pus may 
burrow beneath the breast or into the armpit and several 
openings may occur. In very severe cases it is neces- 
sary to make a free incision and remove all of the in- 
fected gland-tissue. Dressings are usually kept in place 
by a breast binder. If the child is to nurse from the 



184 COMPLICATIONS OF THE LYING-IN PERIOD. 

healthy breast, the physician may prefer to use a broad 
roller bandage of flannel, which can be so applied that 
the nipple of the healthy breast is not included in the 
bandage. Nurses in attendance upon a case of breast- 
abscess must remember to cleanse their hands with great 
care, lest they infect the infant or the genital tract of the 
mother, or some portion of their own body. 

PUERPERAL THROMBOSIS OF THE LOWER EXTREM= 
ITIES. 

In the words " milk leg " is shown an ancient delu- 
sion. This name was given to swelling of one or both 
thighs occurring after labor, which was thought to 
be caused by excessive secretion of milk which ran 
from the breast through the veins into the legs, and 
caused the peculiar white and glistening appearance of 
the skin. The proper name of this condition is puer- 
peral thrombosis of the lower extremity. A clot, or plug, 
forms in one or more veins near the brim of the pelvis, 
blood accumulates in the extremity, and the serum, or 
water, of the blood stretches the skin, making it white 
and glistening. In some cases the clots, or plugs, come 
from the uterus ; and if the womb is infected a very dan- 
gerous condition of blood-poisoning will result. In other 
cases infection is not present, but the clot, or plug, is 
formed in the vessel and will gradually become dis- 
solved or absorbed. This condition sometimes follows 
exertion on the part of the patient too soon after con- 
finement. 

The first symptoms are pain in the brim of the pelvis, 
and a feeling of stiffness and weight in the extremity fol- 
lowed by swelling. The treatment usually employed 
consists in elevating the leg, the patient remaining upon 



AFTER-PAINS. 1 85 

her back in bed or in some cases upon a couch, in 
bandaging the leg, and in applying lotions or remedies 
to prevent inflammation of the skin and allay burning 
or painful sensations. 

The physician will improvise an inclined plane, which 
the nurse or physician must cover with cotton-batting or 
other soft material held in place by a bandage. The 
patient's leg and thigh must be raised as high as is com- 
fortable to herself Beginning with the toes, the leg 
should be bandaged and the thigh up to the brim of the 
pelvis with such a bandage as the doctor will order. Some 
physicians do not apply a bandage, but have the leg cov- 
ered with cloths wrung out of some medicinal applica- 
tion. The occluded vein can often be felt like a cord 
extending for several inches below the brim of the pelvis. 
In some cases the physician will order applications made 
directly over this hardened portion. The patient's diet 
is limited in these cases. The nurse is ordered to keep 
the bowels freely open. Recovery usually proceeds 
steadily but slowly. If the patient has chills with 
high fever, blood-poisoning, or pyemia, has developed, 
and the case is very serious. When recovery is well 
advanced the physician may order massage for the swol- 
len limb, which must be given with great gentleness. 
Alcohol sponging, or sponging with boric-acid solution 
or with weak carbolic-acid solution, is often employed in 
these cases. Should the nurse notice blisters or blood- 
spots upon the surface of the limb, she should notify the 
physician at once. 

AFTER=PAINS. 

Patients are sometimes greatly annoyed by contrac- 
tions of the uterus after the child and its appendages 



1 86 COMPLICATIONS OF THE LYING-IN PERIOD. 

have been removed. These are called " after-pains." 
They usually indicate the presence of a clot within the 
womb. They are often excited by the nursing of the 
child, and in highly nervous and anemic patients they 
may become so severe that remedies must be used to 
control them. The nurse should not encourage the 
patient in thinking that slight after-pains are injurious 
or that they produce great suffering. Much can be 
done to influence the mind of the patient in this re- 
gard, and in mild cases after-pains disappear in a few 
days. Where they are severe and prolonged the physi- 
cian may find it necessary to remove a clot from the ute- 
rus with his finger or by the use of a curet. The nurse 
must prepare for such a procedure in strict antiseptic 
fashion, and every antiseptic precaution about the doc- 
tor's hands, the patient, and the nurse should be ob- 
served. 

The nurse should report to the physician at once if the 
womb remains large after delivery and if the patient has 
after-pains. A large clot may be forming, which may 
finally be expelled with a very serious hemorrhage. 
Nurses are sometimes ordered to practise gentle massage 
of the uterus in these cases, to assist in securing good 
contractions and in preventing the formation of a clot. 
Hot applications over the womb, turpentine stupes, hot 
and stimulating drinks, anodyne medicines, fluid extract 
of ergot, strychnin, and quinin are among the remedies 
prescribed in the treatment of this condition. The nurse 
must remember that to a moderate degree after-pains are 
a favorable indication, as they show that the womb is 
contracted, and promise well for involution and a prompt 
recovery. 



CHAPTER XIII. 
PUERPERAL MANIA. 

Insanity may attack the pregnant and puerperal woman 
in several forms. Of these, the most common is 
melancholia, while acute mania may develop and prove 
fatal. In these cases the patient often seeks to destroy 
herself, and endeavors to kill the child. Hence the nurse 
must be exceedingly cautious in the general management 
of these patients. Such cases occur among women in 
whom there is a family history of insanity, or in women 
who are exceedingly nervous or who have had some 
great calamity come upon them during pregnancy. If 
the disease be hereditaiy, the patient's chance for recov- 
ery is not a very good one ; and if the child dies the 
mother is less likely to recover. If, however, the patient 
has previously been strong and well, the chance for re- 
covery is a good one if time and patience be used in the 
treatment. If the child survives, as the acute stage passes 
away the mother will find great comfort in its care. - 

Treatment. — Restraint and absolute quiet are neces- 
sary during the acute stage ; if the disorder develops 
during pregnancy, the patient may become actively 
maniacal during labor. She would then require anesthe- 
sia and the services of sufficient assistants to control her 
thoroughly. Severe lacerations sometimes occur in these 
cases, and the child may be injured by its rapid expulsion. 
After the birth of the child the mother must not be 

187 



155 PUERPERAL MANIA. 

trusted to nurse it. Should the supply of milk be ample, 
an effort may be made to have the mother nurse it, but 
with the closest watchfulness lest she attempts to do it 
injury. When convalescent and quiet an out-door Kfe is 
best adapted for the mother's complete recovery. Her 
feeling for the child should be encouraged in every pos- 
sible way, and her general health built up and made 
. thoroughly good. 

Precautions. — The nurse must remember the abso- 
lute uncertainty attending upon patients of unsound mind. 
The child is never safe in the presence of the mother in 
these cases unless a protector be at hand. The mother 
should never be left alone lest she attempt to destroy 
herself The nurse must also have in mind her own 
safety, and not consent to go into situations where the 
patient could destroy both nurse and herself. The 
nurse can be of the greatest service to the patient, and in 
many cases she will have the satisfaction of seeing the 
patient's reason return and her affection for the child 
develop in a natural and most salutaiy manner. 



CHAPTER XIV. 

PARTIAL OR MIXED FEEDING.— WEANING.— 
ARTIFICIAL FEEDING. 

Advantages of Nursing. — It is a great advantage 
to mother and child to have the child fed by the mother. 
For the mother, it produces vigorous contractions of the 
womb and greatly hastens her recovery. For the child, 
it avoids indigestion and is the best hope that the child 
will survive. Every effort, then, should be made to 
establish and continue nursing. This, however, may 
wholly or partially fail. A mother may be so debilitated 
that ver>^ little milk can form, and the child be in danger 
of failure from lack of nourishment. It may be better to 
assist the mother by partially feeding the child, while 
allowing it to take what the mother can supply. 

Feeding and Nursing. — In these cases the best 
results are obtained by having the mother nurse during 
the night and early morning. When she is at rest a 
quantity of milk sufficient for several meals for the child 
will accumulate, and her rest at night must be taken 
advantage of for this purpose. Milk for the child should 
be prepared in the forenoon, and if the mother nurses the 
infant during the night and in the early morning a fresh 
supply of cows' milk will be ready to supplement the 
mother's nursing. 

Prescription of Food for Infants. — It must be 
distinctly remembered that it is not the part of a trained 

^ 189 



190 PARTIAL OR MIXED FEEDING. 

nurse to prescribe food foi' a7i infant. Those persons who 
know least about the subject are usually most ready to 
advise a mother as to what food she shall give her child. 
Proprietary foods abound and are widely advertised. 
The trained nurse must absolutely decline to recommend 
any form of food whatsoever if she wishes to retain the 
confidence of the medical profession. The physician 
should prescribe the food as he would prescribe medicine, 
giving written or printed directions for its preparation, 
and these orders the nurse must follow. 

Dilution of Cows^ Milk. — The nurse can assist the 
physician very much by correcting certain impressions 
which parents are very likely to have concerning infant 
feeding. Persons are very apt to assert that cows' milk 
prepared for infant feeding is too thin and weak to nourish 
the child. They do not see breast milk under ordinary 
circumstances, as it passes at once from the mother to the 
child. They observe the dilution of cows' milk to a high 
degree, and reason that the milk is too poor to support the 
child. This objection should be met by explaining that 
the mother's milk is also very dilute, and that it contains 
but 3 or 4 per cent, of fat, and 7 per cent, of milk-sugar, 
and between i and 2 per cent, of albuminoid material. 
The dilution of cows' milk is necessary to make it like 
the milk of the mother, for naturally cows' milk contains 
more albuminoid material than does that of the mother. 

Cleanliness with Milk. — The necessity for abso- 
lute cleanliness with milk employed for artificial feeding 
is not always appreciated by parents and caretakers. 
The nurse may explain that in the case of the nursing 
infant the milk passes so directly from the mother to the 
child that germs do not gain access to it. If the cow 
could be milked directly into the child's mouth, there 



PREPARATION OF MILK— BOTTLES. I9I 

would be very little danger that germs would gain 
access to the child's stomach through feeding with cows' 
milk ; but as this is usually impossible, care is necessary. 

Preparation of Milk. — In mixed feeding, physicians 
often prefer to use cows' milk partially digested. Materials 
for peptonizing and pancreatizing milk are furnished for 
this purpose, and printed directions are given for this 
process. In peptonizing and pancreatizing milk care 
must be taken that the milk is not bitter. If it is heated 
too long with the ferment, digestion goes so far that 
compounds are formed which in the body are pro- 
duced in the small intestine. These compounds are 
very soluble, but bitter and unpleasant to the taste. Pep- 
tonized or pancreatized milk must be heated as short a 
time as possible to bring it to the change desired. It 
then remains perfectly sweet and agreeable to the taste. 
In mixed feeding only milk and milk mixtures are neces- 
sary, as the child is too young for some of the articles of 
food which may be used to advantage later. The nurse 
will obtain from the physician precise directions regard- 
ing the preparation of the milk, and these must be con- 
scientiously followed. Such directions usually include 
the care of the bottles and nipples. 

Bottles. — In selecting bottles the nurse must choose 
those of medium size with rounded surfaces, and having 
short necks upon which a rubber nipple may conve- 
niently be placed. Under no circumstances should a 
bottle having a rubber tube and nipple be employed. 
Round bottles of medium size are very convenient, as 
the child can grasp them better when taking its food. 
Bottles must be cleansed by boiling in a solution of 
sodium bicarbonate, rinsing thoroughly with boiled water, 
and keeping in a saturated solution of boric acid. A 



192 PARTIAL OR MIXED FEEDING. 

brush for cleansing bottles can be obtained at milk 
laboratories or at house-furnishing shops. If a bottle 
becomes coated with a layer of albuminoid material, it 
may be necessary to employ a strong alkali or at times 
to use shot in cleaning the bottle. 

Nipples. — The best quality of black rubber nipples 
should be obtained, and care should be taken that the 
holes of the nipples are not too large. The nipples 
should be turned inside out to be cleaned with soap and 
water. They may also be boiled, and should be kept in 
boric-acid solution when not in use. 

Weaning". — By weaning is understood the removal 
of the child from the mother's nourishment so that it is 
fed entirely without her assistance. The decision to take 
so important a step as weaning a child must always be 
made by the physician in attendance, as it entails great 
responsibility. This is a critical time for both the mother 
and the child. 

Weaning may be done by entirely ceasing the nursing 
of the child or by continuing partially to nurse and par- 
tially to feed it. When it is possible to do so the latter 
is usually chosen. If weaning is made necessary because 
the mother's milk fails, she will usually not have much 
trouble from distention of the breasts. If, however, 
weaning is done because the milk disagrees with the 
infant, milk may continue to form abundantly and the 
mother may suffer much discomfort. The nurse must 
always watch the condition of the breasts at weaning, 
and by the practice of massage, by the use of a support- 
ing bandage, and by relieving the breast partially with 
the pump she may prevent serious inconvenience. 
Restriction of the mother's diet for a few days will also 
assist much in checking the secretion of milk. Nurses 



COMPOSITION AND CARE OF COWS' MILK. 1 93 

should do all in their power to discourage the weaning 
of an infant, unless it be done upon the advice of a phy- 
sician. In some cases the mother does not desire the 
trouble of nursing the child. In others, she is too much 
occupied with other affairs, and dislikes the regularity 
and care which nursing brings. She should not, how- 
ever, bring a child into the world unless she is prepared 
to do this duty for her offspring. 

The artificial feeding of an infant is a matter in which 
the faithful and intelligent co-operation of the nurse is of 
the utmost importance. In her own field she can do 
quite as much as the physician to bring about the suc- 
cessful growth of the child. She must necessarily have 
the confidence of the mother as well as that of the 
physician. 

Composition and Care of Cows^ Milk. — As milk 
is the food usually chosen, the nurse must know some- 
thing of the composition and care of milk. The milk of 
cows is usually selected for infant feeding. In some 
cases the milk of goats or of asses is chosen as being 
more easily digested. At the present time there are in 
many cities of the country milk laboratories which furnish 
milk from herds especially fed and kept for this purpose. 
These laboratories also prepare milk in accordance with 
the doctor's directions, and send it to the houses of 
patients. While the preparation of milk at the laboratory 
is a most valuable thing, there are many families who 
cannot afford it, and who turn to the trained nurse for 
assistance in the care of the child. People often purchase 
milk at the laboratory and have the nurse prepare the 
milk at the house of the patient. The milk furnished by 
the Walker-Gordon Laboratories is the best milk avail- 
able in nearly all cases. If this cannot be procured, the 

13 



194 PARTIAL OR MIXED FEEDING. 

mixed milk coming from several sound, healthy cows of 
ordinar)^ breed, fed on clean pasture, should be selected. 
It is well to avoid fine breeds of cattle, as the milk is 
often excessively fat, and such cattle easily become 
tuberculous. Good milk, Hke good wine, when poured 
into a glass and the glass tipped to one side should leave 
a distinct film on the empty side of the glass. Sound 
cows' milk is neutral or but very slightly acid or alkahne 
in reaction, has the characteristic odor of fresh milk, and 
has a dense white color. If put aside in a cool place, 
the fat rises to the top and forms cream. Cream ordi- 
narily obtained by rising from a good quality of milk is 
reckoned at from 12 to 16 per cent, of fat. If cream be 
purchased as separator cream or centrifugal cream, it 
should contain at least 20 per cent, of fat. Some physi- 
cians prefer to employ one kind of cream, and others, the 
other. The physician must specify whether he wishes 
cream obtained by rising to be used or that obtained by 
the separator. The best milk is served to customers in 
glass jars or bottles containing a pint or a quart, tightly 
sealed. So soon as milk is obtained at the house it 
should be put upon ice, and under no circumstances 
should a bottle be opened unless the entire contents of 
the bottle or jar are to be used. If only part of the con- 
tents of the bottle is required, the remainder must be 
used in cooking, when it can be boiled or scalded. 

Mixing and Pasteurising or Sterilising Milk. — 
To keep and prepare milk properly for a child, the nurse 
must have exclusive charge of the refrigerator in which 
the milk is kept. Nothing but milk should be kept in 
this refrigerator. For this purpose what are know^n as 
nursery refrigerators, or sometimes travelling refrigerators, 
are very convenient. Such is a small block tin or zinc 



MIXING AND PASTE URIZING OR STERILIZING MILK. 1 95 

box containing a compartment for ice and one for bottles 
of milk. The melting of the ice is provided for by a 
suitable drain-pan. The refrigerator can be locked, and 
is of convenient size for use in travelling. In addition to 
a nursery refrigerator, apparatus for Pasteurizing or 
sterihzing milk must be at hand. The Arnold sterilizer 
is familiar to all nurses, and answers the purpose conveni- 
ently (Fig. 8i). The Walker-Gordon Laboratory sells a 
sterilizer of excellent construction and convenient shape, 
fitted for the use of a thermometer, so that the degree of 
heat can be accurately known. From the laboratory or 
from a reliable druggist milk-sugar must be obtained in 
convenient quantities, lime-water, and litmus paper. The 
physician may write his formula in tablespoonfuls, or he 
may designate ounces and fractions. If the latter, the 
nurse must have a graduated ounce measure. Brushes 
for cleaning the bottles, bottles and nipples, as already 
described, must be procured. The nurse will require a 
vessel holding from one to two pints, which can be kept 
exclusively for the purpose of mixing the milk and of 
such a character that it can be made absolutely clean. 
Some physicians prefer that the nurse should use a 
definite measure for milk-sugar, while others allow the 
use of the ordinary teaspoon. 

The physician will prescribe that the child should have 
so many ounces of such a mixture at certain intervals. 
Multiplying the number of ounces in each feeding by the 
number of feedings, the nurse ascertains readily the total 
amount required. It is well to provide one or two extra 
bottles, as one bottle may become broken or the child 
may take a little from it and refuse the rest, and the milk 
cannot be used. The physician must distinctly state 
whether he does or does not wish the milk to be boiled 



190 PARTIAL OR MIXED FEEDING. 

before it is taken. It is usual at present not to heat milk 
beyond the point of scalding it for a few moments. This 
is practically Pasteurizing the milk. Strictly speaking, 
heating the milk to 167° F. for six minutes is termed 
Pasteurizing it. To steriHze milk, it is brought to the 
boiling-point, 212° F., and continued at this point for a 
varying time. Some have milk boiled one-half hour, 
others but twenty minutes. It is seldom necessary to 
prepare milk but once in twenty-four hours. If the milk 
be perfectly sound, and the nurse is absolutely clean with 
the utensils employed, and if the ice-chest be a good one 
and absolutely clean. Pasteurized milk will keep readily 
for twenty-four hours or more. Sterilized milk will keep 
much longer. In the majority of cases Pasteurized milk 
is preferred, because sterilized milk does not always 
nourish the child. Where pure, sound milk, in good 
condition, can be obtained, it requires no Pasteurizing or 
sterilizing. The quality of the milk, however, must be 
positively known. 

To prepare the quantity of milk required for twenty- 
four hours, the nurse must ascertain from the doctor's 
orders the amounts of milk, cream, lime-water, sugar of 
milk, and sterilized water required. These various in- 
gredients, taken from clean vessels, should be mixed in 
a porcelain or earthen or agate vessel which has been 
cleansed by boiling. The whole quantity so prepared 
should then be put through a glass funnel into the num- 
ber of bottles selected, so that each bottle contains the 
number of ounces of the mixture to be taken at each 
meal. The bottles are then to be corked with cotton 
which has been made sterile by baking or steaming. The 
bottles are then placed upon ice until time for feeding. 

If the physician desires the milk to be Pasteurized or 



EMERGENCY FEEDING. - 1 97 

sterilized, the bottles are put in a sterilizer or in a pan of 
water upon a fire, and the milk is treated in the manner 
designated. After it has been Pasteurized or steriHzed 
the bottles are placed upon ice, and when a bottle is re- 
quired it is taken from the ice and warmed in a basin of 
water until it feels slightly warm to the hand, the cotton 
stopper is removed, and a nipple taken from the boric- 
acid solution is placed upon the bottle. It is then given 
to the child to nurse. For warming a bottle at night a 
suitable apparatus can be procured at any house-furnish- 
ing shop, which can be placed upon a gas fixture. There 
are also cups heated by electricity for warming milk, 
which are very convenient. They can be connected by 
a wire with an electric light. It is often most useful to 
employ this during the day, as the nurse may not have 
access to a range or stove. By scrupulous cleanliness 
and aseptic precautions on the part of the nurse very 
much can be done to provide proper nutrition for the 
child. 

Emergency Feeding. — Cases sometimes arise in 
which the advice of a competent physician cannot be 
immediately obtained. Under such circumstances the 
nurse must do as well as possible for the infant until a 
physician can arrive. The nurse may find use for the 
following directions : 

The milk should be as pure as possible. The cream 
should have been obtained by rising. To prepare the 
food, ascertain first how many bottles are required. Es- 
timating the number of ounces which may be required 
at a feeding to be three, and the number of feedings in 
twenty-four hours to be ten, this will provide an excess 
of food, as usually but two ounces will be taken at a 
time, and but eight or nine feedings in twenty-four hours. 



198 PARTIAL OR MIXED FEEDING. 

It is best to prepare one quart of food at a time. Mix 
the entire quantity in a perfectly clean vessel ; then place 
in the nursing bottles the number of ounces required for 
each feeding-. Cork the bottles with sterile cotton, place 
them in a pan of water so that the water rises from one- 
third to one-half of the height of the bottle, and scald the 
milk contained in the nursing bottles. To do this, the 
water in the pan must boil and the milk must come to a 
simmer. So soon as this happens the milk must be taken 
from the fire. 

The bottles should then be kept upon ice until the 
milk is required, when the milk should be heated by dip- 
ping it in hot water to a gentle heat. The cotton plug 
may then be removed, a clean rubber nipple placed upon 
the bottle, and the child may take its food from the 
bottle. To make one quart of food for an average 
healthy infant the following may be used : 

Milk, 2f ounces. 

Cream, 5^ " 

Lime-water, \\ " 

Milk-sugar, i-l- 

Water to make i quart. 

For a premature or feeble child, the following may be 
used : 

Milk, 
Cream, 
Lime-water, 
Milk-sugar, 
Water to make 

The nurse in charge of an infant should obtain from 
the physician in the case precise directions for the com- 



If 


ounces. 


2f 


u 


li 


li 


I 


ounce. 


I 


quart. 



MEDICINES AND PROPRIETARY FOODS. 1 99 

position of its food. These directions are given only to 
assist nurses where medical attendance cannot at once be 
obtained. 

Gruels. — In addition to milk prepared under precise 
directions, predigested milk is often used. Physicians 
may dilute milk with barley-water or oatmeal -water. 
The nurse must be able to prepare either of these in a 
suitable manner. 

In making either barley-water or oatmeal-water the 
best quality of meal or grain should be obtained, and 
should be boiled until completely and very thoroughly 
softened. It is not desired that the infant should obtain 
any of the harder or irritating portions of the grain. Ac- 
cordingly it must be made much softer than when eaten 
by adults. The gruel should be strained through sterile 
cheesecloth or gauze, and the fluid so obtained may be 
used to dilute the child's milk. This may be added to a 
bottle containing milk, cream, Hme-water, and milk-sugar 
without making an unpalatable mixture. 

Beef -juice. — Beef-juice is sometimes added to the 
bottle of a young child, or in cases of illness may be 
given to the child instead of milk. It is prepared by 
selecting a good piece of steak, broiling it on both sides 
quickly before a hot fire, and then squeezing the juice 
with a lemon-squeezer. Children sometimes take this 
better when a little salt is added to it. White-of-egg 
water is prepared by beating up the white of a fresh ^g<g 
with four to six ounces of pure water. This may be 
sweetened with sugar of milk to an agreeable taste. 

Medicines and Proprietary Foods. — Medicines 
are sometimes added to the child's bottle. In such cases 
the nurse must be careful to follow the exact doses pre- 
scribed, and to watch for the effects of these remedies, 



200 PARTIAL OR MIXED FEEDING. 

Patented foods are largely manufactured and advertised, 
and are claimed to take the place of any other form of 
nourishment. Under no circumstances should a iiurse use 
or advise the employme7it of 07ie of these preparations. 
Such responsibility must be taken by the doctor only. 

Feeding without Bottle.— Cases are sometimes 
seen in which it is almost impossible to induce the child 
to nurse through a bottle. Food must then be given by 
a medicine-dropper or by a spoon. It is hard to main- 
tain strict asepsis with such feeding, but the nurse can at 
least be absolutely clean, and this is often sufficient. 

Colic. — Nurses must be cautioned to avoid giving to 
children mixtures for colic. Various teas, whiskey, 
brandy, peppermint, gin, hot water, cold water, sugar, 
salt, and various other substances are given to nursing 
children to relieve coHc. In the absence of medical at- 
tendance the nurse should content herself with emptying 
the child's rectum with an injection of warm soapsuds, 
and with giving the child water as hot as it will take it, 
to which are added a few drops of essence of peppermint. 
Further treatment should come from the physician. 

Record of Feeding. — It is a great convenience to a 
physician in treating an artificially fed child if the nurse 
will record the number of feedings and the amount of 
food actually taken. In this way an accurate idea is 
gained of the amount of nourishment which the child is 
really obtaining. 

Infant's Stools.— Nurses should be familiar with the 
appearance of the stools in breast-fed and artificially fed 
infants. In healthy breast-fed children, when digestion 
has become established, the stools are bright yellow, two 
or three in twenty-four hours, and the consistence of a 
soft paste. When the infant is fed upon cows' milk the 



INDIGESTION — THE CHILD'S HABITS. 20I 

stools are lighter in color, thick, and more tenacious. 
Sometimes a distinct curd can be seen. If the nurse will 
take a couple of bits of stick, she can tease out the curds 
and gain a good idea of their toughness and firmness. 
The healthy infant's discharges are neutral or slightly 
acid. If strong acidity be present, or if the stools are 
markedly alkaline in reaction, some disorder of digestion 
is present. Should the stools be green with mucus, 
blood, or pus, the nurse must report at once to the 
physician. A healthy infant has from one to three stools 
daily. 

Indigestion. — Both nursing and artificially fed infants 
are very often troubled with colic and indigestion. This 
is shown by crying, distention of the abdomen, and dis- 
charges of gas from the intestine or from the mouth. 
Few infants escape a little colic during their early days. 
Should this continue the attention of the physician must 
be drawn to it as indicating some disagreement of the 
child's food or some abnormal condition of its bowels. 
To relieve simple colic, the child should be laid upon its 
stomach against a warm object. Hot water and pepper- 
mint, as already described, may be given. A rectal 
injection of warm soapsuds or of one ounce of warm 
sweet oil may also be used. The nurse must not be 
deceived in imagining that the child has colic because it 
cries. Its diaper may be wet, or a pin or some portion 
of its clothing may be irritating the skin. Thirst is often 
mistaken for colic, and several teaspoonfuls of water will 
often cause a crying child to be quiet. Gentle massage 
of the abdomen is very useful in these cases to aid the 
expulsion of gas. 

The Child^S Habits. — It is often necessary to form 
proper habits of eating and sleeping in the infant. The 



202 PARTIAL OR MIXED FEEDING. 

usual tendency of the newborn infant is to sleep during 
the day and remain awake during the night. This must 
be broken up by waking the child during the day at 
regular intervals and feeding it. It should be fed at night 
at its regular time only ; and if it be made comfortable 
and given plenty of water, it may be allowed to cry for a 
time until it learns that it will not be taken up. 

Constipation or Diarrhea. — The nurse must report 
to the physician the occurrence of constipation or diarrhea 
in the infant. A perfectly healthy child may have but 
one bowel movement in twenty-four hours, and that a 
normal one. Most infants have two movements in twenty- 
four hours, and occasionally three. It is not the number, 
but the character of the movements which makes them 
of especial importance. In cases of chronic constipation 
in infants the doctor will prescribe appropriate remedies. 
The nurse may use to advantage rectal injections of warm 
sweet oil, with massage of the intestine after the morning 
bath. 



CHAPTER XV. 
CARE OF PREMATURELY BORN CHILDREN. 

Pregnancy may be interrupted accidentally, or it may 
be necessary to bring on labor to save the life of the 
mother or child. Prematurely born children require 
especial care and very close attention. The most pre- 
mature child that has been successfully raised was born 
after a gestation of twenty-six weeks. Usually, how- 
ever, a child must be seven or eight months advanced to 
survive. 

The dangers to which prematurely born children are 
exposed arise in the sudden change of temperature from 
the mother's womb to the external world, and in the 
difficulty in digestion which the feebleness of the child 
produces. When it is seen that the pregnancy is to 
terminate prematurely, artificial warm shelter for the child 
must be prepared and arrangements made to feed it. 

Incubation. — Incubators are chambers, or boxes, 
kept at a comparatively high temperature, in which pre- 
maturely born children may be kept until they are suffi- 
ciently vigorous to endure the ordinary temperature. 
Some of these are elaborate, with metal frames and glass 
sides, containing apparatus for heating and circulating 
water to maintain the temperature, and also having appa- 
ratus to inject oxygen gas or oxygenated air. These are 
interesting as scientific instruments, but are not of much 
practical importance. A simple and useful incubator is 
modelled after a French apparatus, and has been found 

203 



204 CARE OF PREMATURELY BORN CHILDREN. 

practically satisfactory. It consists of a wooden box 
having a glass lid which can be removed. About one- 
fourth of the distance from the bottom of the box is a 
false bottom or berth, which covers three-fourths of the 
floor of the box. Beneath this berth or false bottom are 
placed cans or bottles containing hot water. They are 
introduced by drawing back a slide which covers the 
space between the bottom of the box and the berth. At 
one end is a square opening or air window, which may 
be wholly or partly covered by a slide. At one corner 
of the upper surface of the incubator is a tube to permit 
the escape of the heated air. A bed is made upon the 
false bottom with a blanket or pillow, and the child is 
placed upon this. The hot cans or bottles are put in the 
space in the bottom, the air window is opened, air enters 
at the bottom, passing over the hot bottles, and escapes 
at the top through the air tube. A thermometer placed 
beneath the glass lid enables the nurse to read the tem- 
perature of the interior of the incubator. Such a simple 
apparatus costs but little, and the usual degrees of tem- 
perature required are readily obtained by re-filling one 
of the bottles or cans at hourly intervals. 

When it is not convenient to obtain an incubator an 
excellent substitute is found in the ordinary clothes- 
basket, in the bottom of which hot cans or hot bottles 
may be placed, two or more rolls of blankets being put 
around the cans to make a floor, and to keep the child 
from coming in contact with the cans. A blanket should 
be so unfolded as to line the basket completely, and the 
child placed upon a thickly folded blanket, with its head 
slightly higher than the feet. Other heated cans or bot- 
tles may be placed between the basket and the blanket 
which lines it, and thus the child may be kept thoroughly 



Fig. 62. — Incubator. 




Fig. 63. — Clothes-basket incubator. 



FRESH AIR— DRESSING THE CHILD. 205 

warm. The advantage of the clothes-basket Hes in the 
fact that the child can readily obtain an abundance of air, 
and in the ease with which it may be improvised. 

Fresh Air. — It is very important that the premature 
infant shall obtain abundant air no matter what apparatus 
is employed. The incubator or basket should never be 
placed upon the floor, but upon a table three or four feet 
above the floor. This is more convenient for the nurse, 
and gives the child a much better circulation of air. If 
the weather be cold, the basket should be placed in a 
room with an open fire, and the room should be freely 
ventilated. The doctor should prescribe the degree of 
temperature at w^hich he wishes the child to be kept. 
This will range from 95° to 85° F. in the majority of 
cases. 

Dressing the Child. — While it is of the greatest 
importance that artificial heat be supplied for the child, 
the most careful arrangements in this regard may be 
defeated by a little careless exposure. When a prema- 
ture child is born it should at once be taken before an 
open fire, wrapped in blankets, and after it has breathed 
well it should be thoroughly oiled with sterile olive oil. 
The vernix caseosa and oil should be removed by rub- 
bing the child's body with sterile cotton. If the scalp 
and face be soiled, they may be quickly sponged with 
warm sterile water and quickly dried. The child should 
then be bandaged in thin carded lambs' wool, a layer of 
from one-half inch to an inch thick being placed about 
the body and limbs, leaving the orifice of the excretory 
organs without covering. This wool should be held in 
place by bandages of cheesecloth, which are very light 
and very easily adjusted. A very thin flannel slip may 
then be placed on the child, although this is in most 



206 CARE OF PREMATURELY BORN CHILDREN. 

cases unnecessary. Premature infants which move and 
cry vigorously and promise to do well, may not be ban- 
daged, but put in a flannel bag tied at the bottom. This 
permits free motion. Over the orifice of the bladder and 
bowel a handful of sterile cotton or wool should be 
placed. The child should be laid in the incubator, and 
should not be removed without the doctor's orders. 

Feeding. — When it is necessary to feed such a child 
the mother's breast should be pumped or exhausted by 
pressure and the milk placed in a small cup in a basin 
of warm water. It should be taken at once to the child 
and dropped into the child's mouth from a medicine- 
dropper. Where it is difficult to feed a premature infant, 
milk may be taken from the mother's breast, placed in a 
small cup or glass in a basin of warm water, and if it 
cannot swallow, the milk may be introduced into its 
stomach by passing a small catheter into the stomach 
and pouring the milk through a funnel attached to the 
catheter. At times where there is difficulty in introduc- 
ing the tube through the mouth, it may be introduced 
through the nose. Occasionally, nurses become very 
proficient in the use of a small feeding-cup with a spout, 
which enables them to introduce the milk far back in 
the throat. The doctor should prescribe the number of 
drams or drops which should be given, and the intervals 
of administration. Where the .mother has no nourish- 
ment for the child or where her milk is slow in forming, 
the doctor will prescribe other nourishment for it. Pre- 
digested milk diluted with barley-water is often employed 
for this purpose. 

Stimulation and General Care. — Prematurely 
born children usually require stimulation. The physi- 
cian will order the kind of stimulus and the dose, and 



STIMULATION AND GENERAL CARE. 20/ 

this is best administered considerably diluted. Thus the 
child will obtain its nourishment, drink, and stimulation 
at regular interv^als. The discharges from the bladder 
and bowels are received upon the sterile cotton or gauze 
placed between the thighs and beneath the child, and 
this should be removed and the parts thoroughly dried 
with sterile cotton as often as necessary. By close atten- 
tion it is possible to keep such an infant clean and in a 
thoroughly sound condition. Should the child become 
uneasy the room may be warmed, the lid of the incuba- 
tor removed, or the blanket covering the basket, and the 
bandages and wool removed gradually, the child's skin 
inspected, again rubbed with oil, and the wool and band- 
ages replaced. The child should not be taken from the 
incubator if it can possibly be avoided. It is interesting 
to notice that such children cry but little, and seem more 
comfortable than children in the usual condition. This 
is probably due to their freedom from disturbance. When 
the temperature falls below the point of comfort the child 
will immediately cry. Should the temperature be too 
high the child will breathe rapidly and seem oppressed. 

It is especially advantageous to premature children if 
they can have sun baths. These are of course useful 
only in the colder months of the year and on days when 
the sun shines brightly. It is better not to undress the 
child completely, but to allow its body to be covered 
with one thickness of light flannel. Care should be 
taken to protect the eyes by a bandage or cap. It will 
do the child no harm to sleep during the sun bath. 

Premature children often have attacks of dyspnea and 
syncope, with very bad color of the face, which are ex- 
tremely grave. Oxygen for inhalation should be kept in 
readiness for these cases, and in addition to other treat- 



208 CARE OF PREMATURELY BORN CHILDREN. 

ment ordered by the physician, oxygen may be inhaled. 
The nurse should allow the child to inhale oxygen. To 
accompHsh this a mouth-piece or face-mask will be 
needed. 

Such children should not be bathed in a tub until they 
have come to the full period of maturity, and have 
firmly established their health and vigor. They may be 
kept clean by sponge bathing when they are sufficiently 
strong. If care is taken to massage the breasts, and to use 
a breast-pump regularly and gently, the mother will usually 
have a sufficient supply of milk. It is difficult to know 
the weight of the smallest child prematurely born which 
has survived. In the writer's experience, twin children, 
one weighing a trifle over three and the other two and 
three-quarters pounds, have developed into remarkably 
healthy children. In this case the smaller child was 
dressed in doll's clothing for some time, as the ordinary 
infant's clothing was much too large. These children 
were kept in an incubator for nearly six weeks after 
birth. 



CHAPTER XVI. 

DISORDERS OF INFANCY. 

CONSTIPATION. 

Infants may be much annoyed by constipation, and 
the condition may become difficult to remedy. It must 
not be allowed to continue, because straining and difficult 
defecation may bring about prolapse of the bowel and 
much suffering result. The constipation of an infant is a 
relative and not an absolute condition. Children have 
remained in perfect health who had but one bowel move- 
ment in two days. This, however, is the exception and 
not the rule. When the movements are hard, tough, 
and resisting when one examines them, and when the 
matter is ejected with difficulty, the child straining and 
crying during defecation, the condition demands active 
relief. The physician will see that the food is of proper 
quality and quantity. If the child be nursing, he may 
order a change in the diet of the mother. It is usual to 
employ a diet composed largely of vegetables, selected 
fruits, cereals, with a moderate quantity of sweet material 
and very little meat. 

Abdominal Massage. — The nurse in such a case is 
often directed to give the child abdominal massage after 
the morning bath. The child is placed upon its back 
upon a blanket or upon the flannel bathing-apron ; the 
nurse's hands must be warm and clean, and the hand 
which is to be appHed to the abdomen should be lubri- 

14 209 



2IO DISORDERS OF INFANCY. 

cated with sterile olive oil. The rubbing should begin at 
the lower portion of the right side of the abdomen, and 
follow the course of the large intestine up upon the right 
side, across just above the umbilicus, and down upon the 
left side. This manipulation is usually very agreeable to 
the child, and will sometimes cause an attack of colic to 
cease. The pressure should be a gentle one, and the 
manipulation may be continued from ten to twenty 
minutes. 

Suppositories and Injections. — Suppositories of 
various kinds are ordered for the constipation of infants. 
Soap-stick is a suppository made by w^hittling a piece of 
soap into a convenient shape, when it may be slightly 
moistened with warm water and introduced within the 
intestine. The objection to soap-stick is the fact that 
soap is irritating to the mucous membrane of the bowel 
in some cases. Gluten suppositories dipped in olive oil 
are less irritating than soap-stick. Glycerin suppositories 
are made of small size for infant's use, and are preferred 
by some. Nurses are often directed to inject into the 
bowel in these cases an ounce of warm olive oil. The 
best syringe for this purpose is what is called the infant's 
enema syringe, a moderately firm ball of rubber and a 
short nozzle. If a piston syringe is used, care must be 
taken that but little force is employed. A Davidson 
syringe should not be used. It is practically impossible 
to introduce oil by means of a fountain-syringe. If soap- 
and-water enemas are prescribed, the nurse must watch 
carefully for signs of irritation in the mucous membrane 
of the bowel. Some children bear soap-and- water 
enemas very badly. The injection of glycerin is not 
often practised with infants. 

Medicines. — Laxative medicines are used with infants 



THRUSH. 21 J 

as with adults. The dose must be accurately prescribed 
by the physician, and also the time of administration. It 
will be remembered that infants take oils of various kinds 
without very much difficulty as a rule. Syrups are also 
easily taken, while bitter drugs and pills are given with 
difficulty. Powders combined with sugar of milk may 
be placed upon the tongue and will be swallowed without 
difficulty. 

Habits. — The nurse may render the child great ser- 
vice by forming habits of regularity in the movements of 
the bowels. Morning and night should be the rule in 
infants, and if this be once established the adult will 
profit by it in later life. Constipation often shows itself 
by restlessness and fretfulness at night. If the attention 
of the physician be called to this, he will usually permit 
the nurse to empty the child's bowel just before the 
usual hour for putting it to bed. In this w^ay discomfort 
is avoided during the night to both mother and child. 
Nurses must not forget that the free use of water is as 
necessary in avoiding constipation with infants as in 
adults. 

DISORDERS OF THE MOUTH AND GUMS. 

The mouth of the healthy infant should be clean and 
the mucous membrane a pinkish red. In certain portions 
of the mouth there are tissues which when normal in 
color are pearly gray. These can be distinguished, how- 
ever, from patches of membrane or ulcers upon the 
mucous membrane. The child's mouth may be infected 
and bacteria may grow and multiply within its cavity. 

Thrush. — Thrush, or sprue, is the growth of a fungus 
upon the tongue and the mucous membrane of the mouth. 
It forms in white patches of greater or lesser extent, 



212 DISORDERS OF INFANCY. 

which can be removed by gently rubbing the part with 
soft hnen. While this is not a serious condition as 
regards hfe, it is annoying to the child, and should large 
quantities of this fungus be swallowed the child's stomach 
and bowels might become disordered as the result. In 
the treatment of this condition the physician will pre- 
scribe a simple antiseptic. This may be applied in spray 
or by the finger, using bits of soft linen wet in the solu- 
tion. Sometimes the child is given such a drug in com- 
bination with a sweet substance and permitted to swallow 
it. When treating such a condition the nurse must be 
very careful to be gentle. The mucous membrane of 
the mouth is dehcate, and if the nurse is rough or care- 
less in her manipulations she may wound the delicate 
tissue and give rise to absorption and to ulceration. 
Apparatus used for the treatment of such a condition 
should be sterilized by boiling at frequent intervals. If 
strict asepsis be practised under good treatment, the con- 
dition usually disappears. It is much less common with 
patients in whom the nipple is carefully cleansed, and 
where the child is not permitted to lie with the nipple in 
its mouth or to nurse too frequently. 

Other germs than thrush may affect the infant'^ 
mouth. The gonococcus may cause ulceration or inflam- 
mation, and germs of sepsis may be present. Yellow 
spots with very red tissue around them, or patches of 
grayish membrane, indicate dangerous conditions, and 
must be immediately reported to the physician. A 
bleeding tendency of the mouth and gums is occasionally 
observed in infants. This is a serious matter, and should 
immediately be reported to the physician in charge. The 
gums are dark, swollen, and purplish, and bleed to the 
slightest touch. In other cases the gums are not swollen, 



DISEASES OF THE LUNGS IN INFANTS. 21 3 

but are dark red, and the blood seems to ooze from them 
without apparent cause. Septic infection may be present 
in these cases, and aseptic precautions must be taken in 
the care of the child's mouth and of the mother's nipple. 
Dentition. — Parents are usually much interested in 
the possible presence or coming of teeth. Infants are 
sometimes born with one or two teeth. In one case 
under the writer's observation it was necessary to remove 
with hemostatic forceps a small incisor tooth which gave 
the mother great pain when the child nursed. It is not 
usual for teeth to begin to make their appearance until 
the child is six or seven months old. The teeth are 
formed in the jaw in little cavities or nests. If the child 
is exceedingly well developed, the teeth will begin to 
work their way gradually up to the gum two months or 
more before the actual coming through of the teeth. If 
the child is in a perfectly normal condition, this will 
occasion practically no discomfort. In healthy children 
teeth come imperceptibly. If, however, the child is ill 
nourished, excessively nervous, and badly cared for, the 
coming of the teeth often occasions much disturbance 
and distress. The nurse should explain to the parents 
the usual course of dentition, and thus relieve them of 
unnecessary anxiety. 

DISEASES OF THE LUNGS IN INFANTS. 

Infants may have diseases of the lungs, as well as dis- 
orders of the digestive organs. Very rapid and labored 
breathing, with a harsh sensation conveyed to the fingers 
when laid upon the chest, fever, wide dilatation of the 
nostrils, a pale and bluish color of the face, are symptoms 
of the most usual form of pneumonia in infants. In 
some cases this disorder may arise within a few days after 



214 DISORDERS OF INFANCY. 

the birth of the child, from the entrance of septic matter 
into the air-passages during labor. After prolonged and 
difficult labor the child may develop a serious or fatal 
pulmonary condition caused by pressure in the birth- 
canal. This is usually attended by rapid breathing, par- 
tial or complete unconsciousness, and finally by convul- 
sions. 

In pulmonary diseases of infants the physician will 
order stimulating treatment. The nurse must be careful 
to administer stimulants with as great regularity as pos- 
sible. Alcohol and some form of ammonia are the sub- 
stances usually employed. When sedative medicine is 
ordered the nurse must watch with especial care that the 
child does not become depressed under its use. Weak- 
ness, failing breathing, and increase in pallor should be 
detected and reported at once. It is difficult to feed 
infants with pulmonary* disorders, and sometimes milk 
feeding must be abandoned, and broth, beef-juice, or 
dilute gruel used instead. Rectal feeding is sometimes 
employed, and also the administration of stimulants by 
the bowel. 

External Applications. — An important part of the 
treatment of lung diseases in infants consists in external 
appHcations. These may be hot or cold, the latter being 
usually employed. A useful method consists in soaking 
a piece of loose flannel, wide enough to extend from the 
umbilicus to the throat, in water at a temperature pre- 
scribed by the physician, wringing it moderately dry, 
sprinkling it with spirits of turpentine, spirits of camphor, 
or alcohol, as ordered by the physician, and wrapping it 
about the child. Over this is placed one thickness only 
of thin flannel. In some cases no outer thickness is used. 
The nurse should watch the child under this treatment, 



EXTERNAL APPLICATIONS. 21 5 

taking the temperature within one hour after the pack 
has been appHed. It will usually be found that a reduc- 
tion of from one to two degrees has occurred. Should 
this not be the case, it is usual to order the pack to be 
renewed, using water at a lower degree of temperature. 
In some cases, in addition to the pack, an ice-bag is 
placed over the back between the shoulder-blades for 
additional effect. 

In children who are treated in this way the nurse must 
take additional precautions to avoid shock. The tem- 
perature of the pack must be that prescribed by the 
physician in charge, and it is customary to order stimu- 
lants, to be taken at the time of the pack. 

In addition to the appHcations already described, 
simple counter-irritant applications are often 
made. These usually consist of some combination of oil 
with a counter-irritant which can be applied by gentle 
but deep friction. Olive oil (three parts) and spirits of 
turpentine (one part) ; amber oil ; chloroform liniment 
(one part) and olive oil (two parts) ; and camphorated oil 
are some of the applications ordered. The front and 
back of the child's chest are rubbed gently but thor- 
oughly with the preparation, and a loose Hght flannel is 
pinned about the chest. 

In critical cases an infant is sometimes placed in a 
bath or in a body pack. The use of baths or exter- 
nal applications, especially if they be cold, may occasion 
alarm to the mother, and cause her to fear that the child 
will suffer from shock. The nurse will usually be able 
by tact and kindness to show her that her fears are un- 
necessary. 



2l6 DISORDERS OF INFANCY. 

SEPTIC INFECTION IN INFANTS. 

Children are sometimes attacked with septic infection 
derived from the mother's blood before birth or by con- 
tact with some septic object. The umbilicus may ulcer- 
ate, being wholly or partially covered with a yellowish- 
gray deposit ; there may be ulcers in the mouth and 
about the anus or the genital organs. Dark-reddish 
spots beneath the skin and oozing of bloody fluid from 
the mouth and bowel may also be present. 

The nurse should at once report any of these symp- 
toms to the attending physician. If the umbilicus be 
infected, he will prescribe local antiseptic treatment, 
which must be carried out with care and regularity. In 
cases in which the blood is infected, and in which oozing 
of blood occurs, local treatment is of little avail. The 
nurse must keep the child strictly clean and be careful 
to irritate oozing and bleeding surfaces as little as pos- 
sible. 

WOUNDS AND INJURIES OF INFANTS. 

After severe and prolonged labor the child may be 
born with the cranium distorted and the scalp bruised, 
or even wounded. After breech labor the upper portion 
of the child's body may be found injured. The pressure 
of forceps in difficult extraction may temporarily inter- 
fere with the nerves supplying the muscles of the face, 
and the face may be drawn to one side for a few days. 
One eye will often be swollen entirely, or partially shut 
for a short time after a difficult labor. Very rarely a 
fetal bone is broken during the labor. Recently the 
writer had under his care an infant born without medi- 
cal assistance. The woman who was with the mother 



WOUNDS AND INJURIES OF INFANTS. 21/ 

became frightened because the hand of the child ap- 
peared at the side of the head during the birth. Seizing 
the hand, the woman made strong traction upon the 
arm, breaking it. 

The nurse may comfort the mother with the infor- 
mation that swelling and bruising of the cranium will 
rapidly disappear after the first few days of life. Un- 
less deep, wounds and scratches require usually no 
dressing. 

They should be sponged with sterile water when the 
child is washed, and allowed to dry thoroughly. A small 
scab of serum and blood will usually form, which is an 
efficient and useful dressing. Should injuries be severe, 
aseptic dressings must be applied. Antiseptics should be 
used with great care in infants, lest absorption and pois- 
oning result. In cases of fracture the physician will fit 
proper splints carefully padded and held in place with 
cheesecloth bandages. It is sometimes necessary to use 
the child's body as a splint, bandaging the child's arm 
against the side. In such cases the child cannot be put 
in the tub until the fracture is united. Unless injuries be 
severe, infants usually recover with little or no deformity. 
The nurse should encourage anxious parents with this 
knowledge. 

The skin of an infant is so sensitive that nurses must 
be cautioned in the use of external applications. A hot 
bottle or hot-water bag laid against the body of a new- 
born child, although several thicknesses of flannel inter- 
vened, has produced a severe burn. This is especially 
likely to happen if the child's body be wet or the flannel 
be damp. In using such applications nurses must be 
cautious to avoid injury. 



2l8 DISORDERS OF INFANCY. 

BLEEDING FROM THE UMBILICUS; PROTRUDING 
UMBILICUS. 

When bleeding occurs from the umbilicus the 

nurse may stop it for the moment by making pressure 
with sterile gauze at the point of bleeding. The physi- 
cian must be immediately summoned. Hot water and 
antiseptic solutions must be in readiness. If the physi- 
cian does not arrive promptly and pressure from a com- 
press control the bleeding, the nurse may bandage a 
compress upon the umbilicus by a snugly fitting abdom- 
inal bandage. The case should not go, however, without 
the attendance of a physician. 

After the umbilical cord separates the granulating sur- 
face at the umbilicus retracts, and a firm scar forms which 
effectually closes the umbilical ring. In some cases 
granulations form about the stump of the cord, and 
may bleed if irritated or touched by a dressing. The 
attention of the physician should be called to this state, 
when applications will be made to remedy the evil. 

After the umbilicus has healed a protrusion of the 
tissues beneath the umbilical ring may occur. When 
the infant cries or coughs a tumor about as large as the 
end of the little finger is forced outward. If this be car- 
ried back by the tip of the little finger, a small ring can 
be felt, which is the contracting umbilical ring. To pre- 
vent this protrusion various sorts of pads and applica- 
tions are used. A fairly efficient support is made by 
stitching sterile gauze into a pad an inch square. This 
is held in place by an abdominal binder of soft, elastic 
flannel. Where difficulty is experienced in retaining a 
pad or retentive dressing adhesive plaster may be used. 
If such is the case, the nurse must take care that 
when the adhesive strips are changed the child's skin 



ER UP riONS IN INF A NTS. 2 1 9 

beneath them is thoroughly cleansed with soap and 
water, and then with alcohol and water. Unless caution 
is exercised the skin may become sore. Circular pads 
cut from cardboard, coins covered with linen or sur- 
geons' lint, or any smooth circular object may be tried 
as an appropriate support. The nurse may comfort the 
parents by informing them that few of these cases give 
rise to serious trouble or persist to adult life. When the 
case becomes chronic the doctor may prescribe a hard- 
rubber truss, held in position by an abdominal bandage. 

ERUPTIONS IN INFANTS. 

During the first few weeks after birth eruptions of 
various sorts are sometimes observed among infants. A 
small bright-red eruption over almost the entire body 
sometimes follows cleansing of the skin, especially if the 
child be too warmly clothed. An eruption of small 
blisters is mildly contagious, and in neglected cases 
with weak children may become serious. This is usually 
treated by the use of a very mild antiseptic powder or 
lotion. Chafing and excoriation about the genital organs 
and the anus are suggestive of constitutional taint, or 
result from neglect on the part of the nurse. If the 
diapers are not changed promptly and the child kept 
clean, such a condition readily arises. Irritating dis- 
charges from the bowels or bladder also form a cause. 
An eruption, at first dark red or brownish red, then 
fading to a copper color, is suggestive of constitutional 
disease, and must be at once reported to the attending 
physician. An eruption of dark, livid spots beneath the 
skin, becoming gradually larger, while the child has an 
abnormal temperature, with prostration and discharges 
of blood from the umbiHcus, bowels, or mouth, is a 



220 DISORDERS OF INFANCY. 

serious symptom, and must be reported as soon as 
observed. Nurses must remember that dye-stuffs in 
cloth may produce eruptions in children. The applica- 
tion to the body of an infant of a cheap quality of red 
flannel wrung out of hot water has often produced a 
deceptive eruption. The bites of insects must also be 
kept in mind in these cases. Usually the simplest treat- 
ment possible is ordered, bathing with alcohol and water 
or with boric-acid solution, or the use of simple oint- 
ment. The responsibility of the nurse consists very 
largely in detecting and promptly reporting the occur- 
rence of such an eruption. 



CHAPTER XVII. 
DISORDERS OF INFANCY (Continued). 

OPHTHALMIA NEONATORUM. 

By this is meant infection of the conjunctivae in the 
eyes of infants resulting from the presence of a septic 
germ. The infective agent in many of these cases is the 
gonococcus, or germ causing gonorrhea. This is 
pecuHarly virulent, and blindness occurs in many of 
these patients. Other septic germs may cause ophthal- 
mia, but the results are not so serious as in gonorrheal 
infection. The signs of this disease are redness and 
swelling in the conjunctivae, with the formation of pus, 
which accumulates in the corners of the eyes. The pus 
is usually thick and yellow in color. It is occasionally 
very thin, dark brown or reddish brown. When the 
child is recovering a whitish mucous secretion is often 
present. 

Course and Results. — Unless the disorder be 
checked the inflammation spreads rapidly, the Hds 
become swollen so that the eyes shut, the white of the 
eye becomes a bright and flaming red, the pupils are 
contracted, the discharge is a bright yellow, less thick 
and much more abundant, and the child frets and cries 
with distress, endeavoring to rub the eyes with the 
fingers. The inflammation goes on to the interior of the 
eye. The eyeball swells, and finally ulceration through 
some portion of the eye occurs, followed by shrink- 

221 



222 DISORDERS OF INFANCY. 

ing of the eyeball and entire loss of vision. In cases 
which do not go so far the anterior portion of the eye 
becomes clouded and partially opaque from scar-tissue. 
With this condition the child would have partial vision 
only. The rate at which this inflammation progresses 
depends upon the kind of germ which attacks the eyes 
and the vigor and strength of the infant. If the gono- 
coccus is present and the child a feeble one, blindness 
may result in two or three days. If a germ not so viru- 
lent attacks a strong and healthy child and treatment be 
instituted, the inflammation will be checked in forty-eight 
hours. The complete cure of this condition requires 
several weeks in most cases. 

Infection. — The nurse must remember that this is an 
active infection, and a particle of matter from the child's 
eyes introduced into her own will cause an active inflam- 
mation and may result in the loss of her sight. This 
matter, when introduced through a cut or pin prick into 
the finger, may set up a septic inflammation. If one eye 
only be infected, the other eye will become involved if 
the secretion passes from one to the other. The case 
must be treated then with promptness and with great 
care and thoroughness, to save the eyes of the child and 
to avoid danger to those who attend it. 

Treatment. — Physicians usually employ the almost 
constant application of cold. Compresses the size of 
a half dollar are cut from surgeons' lint and laid upon 
a cake of ice placed in a pan or basin. The nlirse sits 
with the child upon her lap or in a crib, applying ice 
compresses constantly. To remove the secretion from 
the eyes, douching or washing with an antiseptic fluid 
is employed. A saturated solution of boric acid, mer- 




Fig. 64. — Irrigating infected eyes. 



OPHTHALMIA NEONATORUM. 223 

curie chlorid (i : 8000), normal salt solution, and 
sterile water are the fluids most often required. Spe- 
cial care must be taken that these fluids are of the 
proper strength, as an error in this particular might 
cause serious damage to the eyes. The way of mak- 
ing these applications differs with different physicians. 
Some prefer irrigation, while others cause the fluid 
to be dropped into the eyes from a medicine-drop- 
per. Of the two, the irrigation is much more efficient, 
and is seldom injurious when carefully done. The 
nurse requires a rubber sheet, a slop-jar, a fountain- 
syringe, a medicine-dropper, the solution or solutions 
ordered, several small bits of sterile gauze or cotton, 
and a little sterile oil or vaselin. The glass portion of 
the medicine-dropper is separated from the rubber bulb, 
and is placed in the tube of the fountain-syringe to act 
as a nozzle. When the fluid has been placed in the bag 
the latter is hung about four feet above the child. Hav- 
ing cleansed her hands thoroughly, the nurse spreads 
the rubber sheet upon her lap and takes the child with 
the infected eye lower than the uninfected eye. If the 
child lies upon its side, the posture will be the best for 
this application. The fluid is allowed to run from the 
inner angle of the eye over the lids, passing downward 
and outward. Secretion is soon washed away, and if 
the child does not open the eye the nurse must very 
gently separate the lids with the thumb and finger and 
wash the eye thoroughly. The eye must be washed in a 
careful manner so that absolutely no particle of secretion 
remains (Fig. 64). When this has been accomplished the 
eye should be dried with sterile cotton, and sterile olive 
oil or vasehn should be very lightly rubbed upon the 



224 DISORDERS OF INFANCY. 

outer surface of the lids to prevent the discharge from 
accumulating and contaminating the lids. The intervals 
of irrigation must be as short as is consistent with the 
child's general condition. Every half hour or every 
hour, while the inflammation is active, is not too fre- 
quent, and is often followed by great benefit. If bichlorid 
solutions are used, physicians often order that irrigation 
with normal salt solution be practised immediately after- 
ward. Nurses must take eveiy precaution that the solu- 
tion used does not spatter, as it might carry with it in- 
fected material. 

In addition to irrigation, physicians make applications 
in some cases of strong antiseptic solutions for the rapid 
destruction of the infective germs — silver nitrate, lo to 20 
grains to the ounce, or argyrol. The physician will 
order the eye to be thoroughly cleansed by irrigation, 
and then separating the lids he will drop into the eye the 
silver solution. In other cases he may prefer to use a 
small, soft camel's-hair pencil, dipping it in the silver 
solution and painting the infected surfaces with it. This 
is usually neutralized afterward by pouring normal salt 
solution into the eye. Solutions are sometimes employed 
to dilate the pupil, and the nurse may be ordered to drop 
a certain dose into the eyes at regular inter\'als. In these 
cases she must note the condition of the pupil, and will 
thus be able to know that the medicine is having an 
effect. 

Precautions. — Caution must be exercised that the 
secretions from the eyes or that irrigation fluid does not 
find its way into the mouth, ears, or nostrils. When 
both eyes are infected double labor falls upon the nurse. 
The inflammation is rarely of equal intensity and of 
equal duration, and hence the case is prolonged and 



EARACHE. 225 

trying. Whenever possible two or more nurses should 
be placed in charge of a case of ophthalmia. It is a 
physical impossibility for one nurse to continue the appH- 
cations day and night. It is exceedingly important that 
treatment go on during the night, although it may not 
be so frequent as by day. A child will often sleep while 
compresses are placed upon the eyes, and in some 
cases irrigation but partially rouses the infant. The 
use of rubber gloves is advantageous for the nurse, as it 
diminishes the danger of infection. If, while caring for 
such a patient, the nurse experiences redness, smarting, or 
swelling iii her own eye, she must report at once to a physi- 
cian for treatment. 

In children very badly nourished that are attacked 
with ophthalmia the destruction is sometimes very rapid. 
Perforation may occur, with the discharge of fluid from 
the chambers of the eye and the complete loss of vision. 
Under these circumstances the eye shrinks. In other 
cases the physician may find it necessary to remove the 
eye to lessen the danger to the other. 

EARACHE. 

Infants, by raising the head, crying, and rubbing the 
ear may complain of earache. This is always a serious 
symptom, and especially with young children. The 
nurse should remember to put nothing in the ear with- 
out the direct orders of a physician. He should be sum- 
moned at once, and until he can prescribe the child 
should be turned upon its side, the affected ear resting 
upon a hot-water bottle covered with flannel or some 
other woollen material. If the doctor should order the 
nurse to syringe the ear, she must remember the neces- 
sity for gentleness. A small syringe composed of a 
hollow rubber ball with a soft-rubber tube is best for 

15 



226 DISORDERS OF INFANCY. 

this purpose. The child must be laid with the affected 
ear lower than the other, the solution must be carefully 
and exactly prepared, and the stream of fluid should be 
directed against the wall of the canal of the ear, and not 
directly into the ear. Should anything come from the 
ear it must be reserved for examination by the physician. 
Excruciating pain is sometimes caused by insects gain- 
ing access to the ear. At other times an accumulation 
of wax may bring about earache of a severe character. 
. The nurse must remember, however, that she should not 
introduce anything within the ear without the doctor's 
orders. If an insect should get into the ear, it may be 
killed by dropping in warm, sterile olive oil. 

FOREIGN BODIES IN THE EYE, NOSE, AND THROAT. 

Infants sometimes insert a foreign body into the eye, 
nose, or throat, producing injury and great anxiety on 
the part of the parents. If the affected eye be bandaged 
with sterile gauze or cotton, the foreign body may work 
its way out. The child should be seen by a physician 
as soon as possible. If the child gets something into 
the air-passages and is choking, it should be grasped 
firmly by the thighs and hung head downward, and one 
hand should be placed beneath the forehead bending the 
head slightly back. A second person may strike the child 
between the shoulder-blades, when the foreign body will 
usually come out. Under no circumstances should the 
nurse or caretaker thrust a finger or instrument into the 
nose or mouth, because by so doing the object may be 
driven further in. An infant may swallow a foreign 
body. This is often imagined when it does not really 
occur. Here again the nurse must take care not to in- 
terfere without the advice of a physician. Nothing can 
be done at once to remove the foreign body. It must 



INTUSSUSCEPTION IN INFANTS. 22/ 

remain until it is embedded into the feces, when the fecal 
matter and the foreign body can be removed by the 
administration of a suitable medicine. The temptation 
would be to at once give the child an enema or a purga- 
tive medicine, but this would only result in injury. 

INTUSSUSCEPTION IN INFANTS. 

The intestine in young children is especially Hable to 
become occluded by having a portion of the gut slip into 
an adjacent part. This is known as intussusception. As 
a result, inflammation occurs ; the bowels become ad- 
herent. Unless this is relieved peritonitis and septic in- 
fection will result, and death will follow. The exact 
cause of the accident is unknown. Children in whom 
the tissues are not firm and strongly developed are most 
likely to have it. 

The symptoms of this condition are pain in the abdo- 
men, vomiting, an effort to move the bowels, rapid in- 
crease in the pulse-rate, fever, enormous distention of the 
abdomen with gas, and ultimately unconsciousness and 
death. The first symptoms may be very sHght, and may 
be mistaken for a trifling indigestion. The first impulse 
of the caretaker is to give the child a purgative or laxa- 
tive medicine. This, however, would be a great mistake, 
for the action of the medicine would cause the intestine 
to adhere more firmly, and increase the inflammation. 
Until a surgeon can see the child no effort should be 
made to move the bowels. The child should be given 
broth, soup, or peptonized milk in small quantities. If 
there is delay in obtaining surgical aid, and the child is 
suffering gready, from five to ten drops of paregoric in 
ateaspoonful of water may be given. These cases should 



228 DISORDERS OF INFANCY. 

be brought to the attention of a surgeon as early as pos- 
sible. The only other treatment consists in operation. 
Occasionally physicians obtain good results by giving 
enemas, or by copious lavage of the intestine. 

MALFORMATIONS. 

Infants are sometimes born so dreadfully malformed 
as to be called monsters. Fortunately such rarely sur- 
vive. The nurse must take great care that the mother 
does not see such a child, and that as few people as pos- 
sible should behold it. Exaggerated and cruel stories 
often arise in these cases. Lesser degrees of malforma- 
tions are not uncommon, and often affect the health of 
the child very little. Such are harelip and cleft palate, 
curvatures of the limbs, rudimentary fingers and toes, 
birth-marks, imperforate anus, and phimosis. The nurse 
should not report or comment upon these, but let the 
mother find it out for herself, and allay her anxiety 
by the statement that such a condition can usually be 
cured. Should the anus not be open the child's bowels 
cannot move, and an operation must very soon be per- 
formed. The child will have distress, distended abdo- 
men, with straining efforts to move the bowels. A 
physician must be notified and some form of operation 
undertaken. 

Retention of Urine. — Difficulty in emptying the 
bladder sometimes occurs in male children from phi- 
mosis. When upon urination the foreskin becomes dis- 
tended urine will be retained and undergo decomposition, 
setting up irritation and inflammation. The attention of 
the physician must be called to this, when he will sepa- 
rate adhesions or perform circumcision to relieve the 
difficulty. If adhesions are separated and the foreskin 
is stretched, it will be the duty of the nurse under the 



CIRCUMCISION. 229 

doctor's directions to apply a sterile or antiseptic oil 
once daily after drawing back the foreskin. She must 
also notice swelling or hemorrhage after the breaking up 
of adhesions or after the performance of circumcision. 

Circumcision. — The operation of circumcision is 
done among Hebrews on the eighth day after the birth 
of the child. Antiseptic precautions are often not 
practised by Hebrew operators. With surgeons the 
operation is done under antisepsis. The nurse should 
prepare for this operation a small table upon which is a 
pillow covered by a rubber sheet. Several clean basins, 
hot water, brandy or whiskey, usually ether, antiseptic or 
sterile gauze, a clean nail-brush, mercuric-chlorid tablets, 
and old Hnen should be in readiness. If the child is 
several months old, and strong, the operator may admin- 
ister ether or chloroform. Stitches are often taken during 
this operation, and the nurse may be required to thread 
the doctor's needles, as well as to supply him with gauze 
or cotton sponges. If stitches are not taken, hemorrhage 
is prevented by compressing the parts with a strip of 
sterile lint or gauze. This is wrapped about several 
times firmly, and over this is placed an antiseptic dressing 
with a T-bandage. In all cases in which stitches are 
taken the nurse should watch closely for hemorrhage for 
the first twenty-four hours after the operation. The risk 
of bleeding is less if stitches are taken. Should hemor- 
rhage occur, the doctor must be immediately summoned. 
Until he comes the nurse should apply pressure at the 
bleeding point. The physician will renew the dressing 
himself for the first day or two, and then may instruct 
the nurse to dress the parts. The nurse must prepare 
her hands carefully, making them aseptic, and apply 
ointment or solution as the doctor may order, using 
either a dressing composed of a strip of aseptic material 



230 DISORDERS OF INFANCY. 

or applying a broad piece of aseptic gauze with a T- 
bandage, in such a way that the child's clothing does 
not irritate the wounded surfaces. Strict cleanliness of 
the skin surrounding the site of operation should be 
maintained. If tact and gentleness are used in dressing 
these cases, they are not very difficult to manage. The 
nurse should send at once for the physician for hemor- 
rhage, or great swelling with very dark color of the parts. 
If the child cannot empty the bladder freely, the physi- 
cian must be summoned. 

Among Hebrews it is not usual for a nurse to take any 
part in this operation, as it is a religious rite ; hot water, 
stimulants, old linen, a covered pillow, and a small table 
or several chairs should be provided. 

Dilatation. — When circumcision is not performed the 
physician will practise dilatation and retraction of the 
foreskin, with the application of oil or ointment. The 
nurse will be required to sterilize his probe or forceps, 
and to sterilize olive oil, which is most usually employed. 
The nurse should observe closely how the doctor retracts 
the parts, so that when she is ordered to do so she may 
perform this manipulation in the manner desired: 

Competent physicians examine thoroughly each new- 
born child to detect malformations or abnormalities which 
require treatment. In female children an irritating dis- 
charge from the vulva may be present, which may 
require the use of douches with a warm solution of boric 
acid or sterile water only. Slight curvatures of the legs 
may sometimes be corrected by judicious massage and 
pressure, and this the physician will instruct the nurse to 
do. If extra fingers and toes are small and easily 
detached, they will be ligated and removed. Birth- 
marks cannot be remedied without a more serious pro- 
cedure, to be undertaken later. 



HARE- LIP AND CLEFT PALATE. 23 1 

Hare-lip and Cleft Palate. — By hare-lip is meant 
a failure of the two sides of the upper lip to join properly, 
leaving a triangular gap. By cleft palate we understand 
a failure of the bones which form the roof of the mouth 
to properly unite. Sometimes one of these is present 
without the other, but usually both are observed in the 
same patient. They form a distressing malformation, 
which interferes with the child's nursing or feeding ; and 
if it lives to grow up, makes its speech disagreeable and 
indistinct. This condition is hereditary in many cases. 

When such a child is born, the nurse should not allow 
the mother to see it, if possible, for the first twelve to 
twenty-four hours. This* will give the mother time to 
recover from the fatigue of labor. She should then be 
told of the occurrence, and also informed that many of 
these cases are cured by operation when the child is a 
few months old. When the child attempts to nurse, 
difficulty may be experienced because it cannot close 
the lips properly around the nipple. Unfortunately, but 
little aid can be given in this ; but by repeated efforts the 
child will usually improve in this respect. Where, how- 
ever, the child cannot draw milk from the breast, or if 
the milk does flow, it passes into the nose or wind-pipe, 
this will give rise to coughing and strangling, and may 
set up an infection of the lungs. It is often necessary in 
these cases to pump the mother's milk, and to feed the 
child by a pipet or medicine-dropper. If the milk be 
dropped far back in the mouth, and the child's head be 
suddenly but gently raised, the child can often swallow 
successfully. The mouth should be kept scrupulously 
clean in these cases, with boracic-acid solution to which 
a few drops of glycerin have been added. Where the 
deformity is very bad, it may be necessary to feed the 



232 DISORDERS OF INFANCY. 

child by a catheter or tube passed through the nostril 
into the stomach. 

Operation upon the lip may be done successfully when 
the child is from three to six months old. This is often 
performed without an anesthetic, or under the influence 
of a very small quantity of chloroform. The repair of 
the palate is not usually attempted until the child is from 
eight to eighteen months old. After these operations 
especial care must be taken to keep the mouth thor- 
oughly clean. 

It is sometimes possible to very greatly improve cleft 
palate without a cutting operation. If the hands be thor- 
oughly washed, and the thumb and finger of one hand be 
introduced into the child's mouth and placed at the pos- 
terior extremity of the upper jaw, and firm but gentle 
pressure be made directly toward the center of the mouth, 
the bones can be pressed together. This is but a tempo- 
rary result, but if this be done daily for one or two months, 
considerable progress can be made. This manipulation 
causes the infant to cry in most cases vigorously, but it 
does not disturb the child's digestion, and may be carried 
out in spite of the child's cries. The nurse should en- 
courage the mother to hope and believe that the child's 
condition can be greatly improved, or completely cured. 

Mothers are often curious to know why such malfor- 
mation occurs. While the matter is not perfectly clear, 
it cannot be traced, as a rule, to any one act on the part 
of the mother, n6r can it be proven that anything which 
she saw during her pregnancy brought about this result. 
Malformation occurs through failure of the two halves 
of the skull to properly unite. The condition is heredi- 
tary in some famihes, but without known cause. 



CHAPTER XVIII. 
DISORDERS OF INFANCY (Continued). 

HERNIA. 

Conditions arise with infants which result from con- 
genital weakness or lack of development. Weakness at 
the umbihcal or inguinal rings may cause the protru- 
sion of the lining membrane of the abdomen or of the 
intestine, pushing the membrane before it. Umbilical 
hernia usually disappears spontaneously with the use of 
a simple pad. Inguinal hernia in one or both groins will 
not disappear without the use of a truss. Occasionally 
a pad can be fitted to an inguinal hernia which will give 
temporary relief, but this rarely becomes permanent. 
Great caution is necessary in using permanent trusses 
with infants lest injurious pressure be made and damage 
to the bowel result. 

CYANOSIS. 

When the valve between the chambers of the heart 
does not properly close the blood does not receive its 
needed supply of oxygen, and as a result the color of 
the child is bluish or cyanotic. Such a child breathes 
feebly, has a cold skin, and a peculiar bluish and livid 
appearance of the features. It is not likely to survive, 
although in some cases the child reaches the age of ten 
or fifteen. A slight cold or sudden exertion or nervous 
fit may destroy the life of the child. Such a child must 
be shielded in every possible way from injury and pro- 
tected from extremes of heat and cold. 

^ ^33 



234 DISORDERS OF INFANCY, 



TONQUE=TIE. 



Mothers are often annoyed by the belief that infants 
are tongue-tied. If the child can suck and nurses vigor- 
ously, there is no ground for this belief. Its powers of 
suction may be tried on a rubber nipple or upon the 
finger of a clean hand. It is occasionally necessary for 
a physician to cut the tissue which holds the tongue, and, 
as oozing may follow, the nurse should have at hand 
small pieces of ice and soft sterile Hnen. 

CONSTITUTIONAL DISORDERS. 

Rickets. — Infants may be born rachitic, inheriting 
the disease usually from the mother. In the most com- 
mon variety the cranium only is affected, the dome of 
the skull being broader and thicker than normal. In 
severe cases the cranium, ribs, collar-bones, and long 
bones are also involved, the legs of the child are crooked, 
it is pigeon-breasted, the back is not straight, and the 
cranium is large and heavy. Such children are very 
liable to colds and pulmonary diseases, and to catarrh 
of the intestine. Their care requires thorough and 
patient nursing, with changes of climate and carefully 
selected food. Excessive sweating about the head is 
one of the distressing features from which these children 
suffer. They require sponging with alcohol at night, 
salt baths, massage, oil inunctions, with specially selected 
feeding. With such care it is usually possible to arrest 
the spread of the disease and to bring about at least a 
partial convalescence. For the correction of the limbs 
and alterations in the spine orthopedic apparatus is 
usually worn. While this must be adjusted by an ortho- 
pedic surgeon, it will be the duty of the nurse in charge 



CONSTITUTIONAL DISORDERS. 235 

to see that the skin at points where the apparatus makes 
pressure is kept in sound and healthy condition. 

Tuberculosis. — Under the name of scrofula, a con- 
dition characterized by chronic swelling and tubercular 
infection of the lymphatic glands, sluggish digestion, and 
impaired nervous system is sometimes observed in young 
children. Very rarely the swollen glands undergo sup- 
puration. Pus forms and is evacuated, and the child 
wholly or partially recovers. In other cases the swelling 
in the glands disappears without suppuration. Nurses 
in charge of such children are required to give massage 
and to use salt bathing for the child, predigested and 
carefully prepared food, and to practise inunction with 
oil, and in some cases to rub into the enlarged glands 
medicated ointments. Like rickets, this disorder is 
usually brought to a partial recovery, although the child 
is rarely as strong and healthy as other children. In 
other cases the tubercular infection attacks the joints. 

Hydrocephalus. — By hydrocephalus is understood 
a condition commonly called " water on the brain." The 
head of the child is considerably enlarged, the bones of 
the skull are abnormally wide apart from each other, 
there is unusual bulging at the fontanel, the child is weak 
and ill-developed in other ways, and in the most advanced 
grades of hydrocephalus the child is malformed in various 
portions of the body. Where the head is excessively 
large the physician in charge may be obliged to pierce 
the head before the child can be born. If such a child 
survives its birth, the tendency is for the skull to remain 
large and for the head gradually to increase in size after 
the child passes the first few months of life. In treating 
this condition a surgical procedure may be necessary. 
Thus the spinal canal or the cranium may be opened 



236 DISORDERS OF INFANCY. 

under antiseptic precautions, and fluid allowed to escape. 
For this the nurse must have ready antiseptic dressings, 
antiseptics, stimulants, and the articles usually required 
for operations. Compression bandages are sometimes 
applied to the cranium, but usually without result. 

Marasmus. — Under the name marasmus is described 
a condition of failing nutrition in infants in which they 
become exceedingly wasted, unable to digest and assimi- 
late food, and finally perish from exhaustion. The 
abdomen is drawn in toward the spinal column, the child 
cries and whines almost incessantly while awake, and 
wasting is so extreme that the limbs resemble those of 
an animal or bird. The fat entirely disappears from the 
body and the skin covers the bones loosely. If this 
condition becomes pronounced, it is exceedingly difficult 
to correct. If the slightest variation from proper nutri- 
tion is quickly recognized and taken in hand, the child 
may be rescued from this danger. In the treatment of a 
marasmic infant the nurse will be asked to prepare pre- 
digested foods, to make soups and broths and other 
nutritious liquids, to use irrigation of the intestine, oil 
inunctions, massage, hypodermoclysis, and eveiy means 
available to stimulate the vigor of the infant. If the case 
is taken very promptly and treated thoroughly, recovery 
sometimes follows. Unless these favorable circumstances 
are present the majority of such children perish. 

PARASITES. 

Infants are sometimes attacked by parasites, which 
cause them great annoyance and in some instances posi- 
tive suffering. These may be derived from other children, 
or attendants, or from domestic animals. Dogs and cats 
have several diseases of the skin which they may trans- 



PARASITES. 237 

mit to the human being. One of these is ringworm. 
This is a circular parasitic growth which takes its name 
from the shape formed by the colonies of parasites. Any 
domestic animal suspected of being the cause of the dis- 
ease should be carefully examined and, if necessary, 
removed. The physician will order ointments and bath- 
ing with lotions to destroy the germ. Nurses must 
remember that their own hands and arms may be attacked 
by the same parasite. 

The Itch Insect. — This insect is conveyed from one 
person to another by contact, and burrowing into the 
skin sets up an irritation which results in a pustular 
eruption. When placed under the microscope the itch 
insect is plainly discernible and the diagnosis is clear. The 
physician in charge will order germicidal ointments and 
lotions. Pustules must be opened and pus thoroughly 
washed out of inflamed areas of the skin. If germicides 
are then applied, the parasite is destroyed. 

Bites of other insects, such as mosquitoes, flies, fleas, 
and other vermin, may produce in the skin of a delicate 
infant a severe and puzzling eruption. By careful obser- 
vation the cause of the disorder can be detected and 
appropriate measures taken to prevent its recurrence. 
Very soothing lotions and mild ointments may be used 
as directed by the physician. In severe cases the child 
may become so irritated and may suffer so severely that 
considerable fever may result. 

Intestinal Parasites.— As infants do not take the 
food from which many parasites are derived, we should 
not expect to find among them the same intestinal 
invaders which we find in the adult. What are known 
as thread-worms or seat-worms are occasionally seen in 
infants. As the name indicates, they are small white 



238 DISORDERS OF INFANCY. 

threads found in masses or clumps in the lower bowel, 
and at the edge of the bowel where the mucous mem- 
brane joins the skin. They produce great irritation and 
itching, with mucous secretion from the bowel and 
general discomfort. In treating such a case the nurse 
would be ordered to wash out the bowel very thoroughly, 
and then to apply such lotion and ointment as the doctor 
will prescribe. While excessively annoying, they are not 
especially dangerous, and the nurse may comfort the 
mother and allay her apprehension. 

JAUNDICE. 

Certain variations in the child's physiologic processes 
sometimes occasion anxiety and call for attention. Jaun- 
dice is not uncommonly seen in newborn infants, appear- 
ing from the third to the fifth day after birth. The skin 
is a lemon-yellow or slightly darker, the discoloration 
including the entire body, and being especially noticeable 
in the eyes and face. The urine may be highly colored, 
and it is often found that the bowels have not moved 
freely, and that the stools still consist mostly of meconium. 
The child does not seem especially distressed or fretful, 
although in some cases the appetite is less than normal. 
The treatment of this condition as prescribed by the 
doctor consists in the administration of some appropriate 
medicine, and the use of irrigation of the bowels. Warm 
fluids are usually employed to wash out the intestine, but 
in some cases the temperature is brought down to 70°, 
65°, or 60° F., so that the irrigation may be said to be 
cool. The condition usually disappears in the course of 
a week with good treatment. 



SUPPRESSION- OF URINE. 239 

ENLARGEMENT OF THE BREASTS. 

For some unknown reason the breasts of newborn 
children become enlarged during the first two weeks 
after birth. A thin milky fluid may be present and con- 
siderable distention accompany it. It is usually neces- 
sary to do nothing for this condition, as it generally 
disappears in a few days. Should inflammation and 
suppuration occur, then the infected breast must be 
incised, and the abscess -cavity washed out thoroughly 
and drained under antiseptic precautions. Should the 
infant's breasts be greatly swollen, the sweUing can often 
be controlled by the use of warm fomentations. Then 
soft flannel should be wrung out of water at a temperature 
of 100 to 110° F. Upon this should be sprinkled spirits 
of camphor. Som.e physicians prefer to make applica- 
tions of belladonna ointment diluted with lanolin or 
white vaselin. Such appHcations should be kept in place 
by a smoothly applied and snugly fitting flannel bandage. 

SUPPRESSION OF URINE. 

Much alarm is sometimes felt from the statement that 
the child has passed no urine during the first forty-eight 
hours of its life. The correctness of such a statement is 
very hard to prove. When a child is placed in a warm 
tub-bath, urine is often passed while in the bath, and 
its presence is not detected. Unless the diapers are 
changed frequently and inspected, if the child's urine 
be not highly colored, the passage of water may not be 
observed. 

If the nurse is convinced that the child has not passed 
urine, the doctor will dilate the urethra and pass a small 



240 DISORDERS OF INFANCY. 

sound to see whether there is an obstacle to the passage 
of urine. If this is not the case, then medicinal means 
may be employed to estabhsh the secretion. The use of 
warm fomentations over the back, the application of 
cloths wrung out of warm water over the bladder, the 
administration of medicines by the mouth, plenty of 
water for the child to drink, a warm tub-bath followed 
by massage, are all useful. The application of cloths 
wrung out of warm water and sprinkled with spirits of 
turpentine may be necessary to secure relief. It is 
almost impossible to collect the urine passed by an 
infant, hence we are usually without an accurate idea 
of the quantity really voided. 

PERSISTENCE OF MECONIUM. 

The child's bowel movements should become yellow 
in four or five days after its birth. When this does not 
happen and the movements remain dark and tar-like in 
appearance there is delay in emptying the intestine of its 
natural contents. The physician will prescribe proper 
laxatives, and the nurse may be asked to use lavage or 
injections into the bowel. Unless this condition is 
accompanied with jaundice, with great prostration and 
abnormal temperature, it is usually not a serious matter. 

ECZEMA. 

Under the name " salt rheum " parents are familiar 
with a rough, scaly condition of the skin, behind the 
ears or on the face, which gives the infant great distress. 
Eczema is most often seen in children who inherit some 
nervous pecuharity of digestion. There seems to be a 
curious relationship between the skin and the mucous 



E CZEMA — SCA L P- CR US TS. 24 1 

membrane of the bowels in these cases. The eruption 
is usually most irritating to the child, and it suffers from 
itching so severely that it will usually scratch the rough- 
ened surfaces until they bleed. The physician will pre- 
scribe not only a very careful selection of diet, but he 
will also order the use of ointments and lotions. In 
severe cases large areas of the body affected in this way 
must be protected by bandages. Thus if eczema be 
upon the scalp the child must wear a sort of night-cap, 
which will cover lint on which ointment is applied. If 
on the limbs, ointment is often spread upon surgeons' 
lint and kept in place over the affected part by cheese- 
cloth bandages. The nurse must be competent to apply 
these bandages and to make the necessary dressings as 
the doctor may order. The tendency of these patients 
is to improve as the child grows older. They are often 
of fair and delicate skin, and usually have fine com- 
plexions in later life. 

SCALP=CRUSTS. 

Upon the scalp of infants there is often seen a yellow- 
ish-white crust which mothers imagine comes from dried 
milk. Hence they are often termed " milk-crusts." They 
result from the accumulation of secretion from the oil- 
forming glands of the scalp, and require removal and 
proper care of the scalp afterward. The popular beHef 
sometimes met with, that to remove them is dangerous 
to the child's brain, is absurd. The affected surfaces 
should be thoroughly rubbed with sterile oil. Sterile 
sweet oil or castor oil may be employed. If the crust 
is firm and large, this oil rubbing may be repeated sev- 
eral times at intervals of a few hours or at intervals of a 

16 



242 DISORDERS OF INFANCY. 

day. When the crust has become thoroughly softened 
the scalp should be lathered with very fine soft soap, 
using Castile or the purest quality of shaving-soap. If 
this is gently washed off with warm water, the scalp will 
be found to be clean. A saturated solution of boric acid 
or of borax should be employed until the tendency to 
form a crust ceases. 

CONVULSIONS. 

Infants are sometimes seized with convulsions, and this 
condition is called the eclampsia of the newborn. Such 
a condition usually comes from some point of great irrita- 
tion in the intestines, mouth, the skin, the genital organs, 
or in the brain itself The convulsions are but a symptom 
whose cause must be discovered. A nurse can do but 
little for a child in convulsions without medical advice. 
Should the doctor fail to arrive promptly, she may put 
the child in a warm bath, placing a cloth wrung out of 
cold water on its head, and she may move the bowels 
by a copious injection of warm water or weak Castile 
soapsuds. When the doctor arrives he will prescribe 
medicine to check the convulsions, and will endeavor to 
remove their cause. If the child be teething, it may be 
necessary to lance the gum. For this the nurse may be 
asked to hold the child's head, grasping it gently but 
firmly between her hands. She will often be asked to 
sit, taking the child upon her lap, holding its hands 
with one hand while she draws the head of the child 
against her chest with the other hand placed against the 
forehead. In this way she can usually control a young 
infant. After the gums are lanced, should bleeding be 
excessive ice is often applied, and a small bit of ice 
wrapped in an old clean handkerchief may be pressed 



VA CCINA TION. 243 

firmly against the bleeding point. Soft, clean linen 
dipped in whiskey or brandy is sometimes applied. In 
other cases the nurse will be asked to wash out the 
intestines very thoroughly, to remove decomposing food 
or intestinal secretions. If sedative medicines are given, 
the nurse must watch for their effect with special care, as 
children are susceptible to these drugs. Usually con- 
vulsions are indications of some serious condition, and 
require prompt and efficient treatment. 



VACCINATION. 

While it is not customary to vaccinate very young 
infants, under strict antiseptic precautions and with pure 
lymph it is possible to do so with very little discomfort 
to the child. Vaccination should be as absolutely aseptic 
as possible. We do not wish to destroy the action of the 
virus by antiseptics, but we very much fear lest we may 
introduce with the virus a germ which might bring about 
an inflammation. Vaccination should never be done 
with matter derived from a human being. Only lymph 
selected from sound young animals and thoroughly 
aseptic should be employed. Hence a nurse should 
never allow a crust from a baby's arm to be saved to use 
in vaccinating another person. The physician who per- 
forms the vaccination may do it upon either the arm or 
the leg. In the case of girls it is not uncommon to 
vaccinate upon the leg, to avoid the scar upon the arm. 
As the physician may direct, the site of vaccination 
should be made thoroughly clean and aseptic. The 
nurse should provide for him an antiseptic solution, hot 
water, soap, clean or sterile towels, and a new nail- 
brush. 



244 DISORDERS OF INFANCY. 

The most successful vaccination at present is done by 
the use of lymph in sterile glycerin, put up in hermet- 
ically sealed tubes. Scarification is done with a sterile 
needle ; the lymph is dropped upon the prepared surface 
and is rubbed in with the needle. After this has dried 
precautions must be taken to prevent the clothing of 
the infant from touching the vaccinated spot. Vaccine 
shields which adhere to the skin, forming a disc of 
felt, protecting the arm from the clothing, may be used 
if the physician recommends them. In some cases a 
shield is employed which is fastened about the arm 
or leg with tapes. The principle should be to pro- 
tect the part inoculated from contact. The vesicle will 
usually form in successful vaccinations in from three to 
five or six days. If the vaccination has been done in a 
thoroughly aseptic manner, and if the lymph be pure, 
there is usually very little disturbance of the general 
health. The child may be a little fretful, or may take a 
little less than the usual amount of food, but in many 
cases even this cannot be noticed. The nurse must use 
all diligence to keep the vesicle from being broken, so 
that the lymph which it contains may dry into a firm, 
protecting crust. Under no circumstances should the 
crust be removed unless by the attending physician. If 
the vesicle bursts and lymph runs over the skin, phy- 
sicians usually order the application of sterile dressings 
held in place by cheesecloth bandages or zinc oxid ad- 
hesive plaster. At the end of ten days, or before, the 
crust usually separates, making a whitish scar with a few 
depressions. Vaccination is commonly regarded as an 
unimportant and not especially dangerous affair. If it 
be done in the best manner possible, it very rarely causes 
illness or great discomfort. If it is performed, however, 
in a careless and dirty manner, it may bring about death. 



CHAPTER XIX. 

THE DEVELOPMENT OF THE CHILD. 

Mothers and nurses are always intensely interested 
in the growth and development of the child. Each fully 
developed newborn child is on the average fifty centi- 
meters, or twenty inches, long. The circumference of its 
chest and of the head bears a definite ratio to the length 
of the child's body. In cases in which well-marked dis- 
ease is present this ratio is destroyed, and certain por- 
tions of the body are much larger than normal, while 
other portions are much reduced in size. 

WEIGHT. 

The average infant weighs from six and a half to 
seven and a half pounds at birth. Great variations from 
this average are sometimes seen, as in cases in which a 
child weighs ten or twelve pounds, or in which the weight 
is reduced to three or four pounds. During the first few 
days of life the child loses steadily in weight. This re- 
sults from the discharge through the kidneys and intes- 
tines of matter which has been stored up in the body 
before the child was born. There is in the mother's 
milk not much nourishment for the first few days, and 
hence there is little or nothing to replace the loss. The 
child, however, does not require much, and so there is 
no need to interfere with the child by giving it cows' 
milk or various preparations. So long as its strength is 

245 



246 THE DEVELOPMENT OF THE CHILD. 

good and the mother's milk is forming naturally it is 
best not to interfere. 

After the mother's milk has become established the 
child gains, and continues to gain steadily. The rate of 
this gain is from three to five ounces weekly on the aver- 
age, or about a half ounce daily. This steady increase in 
weight is one of the best indications that the mother's 
milk agrees with the child, and that the child is normally 
developing. It is of great importance that the child 
be weighed at regular and frequent intervals. Nurses 
must impress this upon the minds of mothers and care- 
takers of children, for it is an exceedingly difficult thing 
to obtain a regular weight in the case of most children. 
So soon as the mother is up and about she forgets or 
neglects to weigh the child, and it is only when the child 
becomes ill that attention is drawn to the fact that it is 
deficient in weight and also in vigor. Suitable scales can 
be obtained especially designed for this purpose. It is 
not safe to trust to scales from grocers or other persons 
who sell goods, as the scales are not always accurate. 
In addition, it is very inconvenient to take an infant to 
be weighed, and the surroundings are not always clean 
and inviting The weight should be reported at regular 
intervals to the physician in charge and will be re- 
corded by him. If the mother desires to keep a record, 
she can find books and charts for this purpose easily 
available. In weighing a child it is not always possible 
to weigh it without clothing, but the clothes can after- 
Avard be weighed and the result taken from the weight 
of the child when clothed. If the child ceases to gain in 
weight, the fact must be at once reported to the physi- 
cian in charge. 



LENGTH— THE NERVOUS SYSTEM. 247 

LENGTH. 

Infants grow in length as in weight. The average 
increase for the first six months is four inches in length. 
At birth the child's trunk is much longer than the limbs, 
but the Umbs soon begin to grow and furnish the chief 
increase in the total length of the child. Growth in 
length occurs most markedly when some other physi- 
ologic changes take place. Thus after teething growth 
in length is often very noticeable. Infants sometimes 
increase in length much more rapidly than in weight. 
This fact need give no anxiety if the child remains strong 
and vigorous. Children inherit the peculiarities of parents 
in stature and weight. This naturally influences the way 
in which the child develops. Some babies are taller and 
thinner than others, but so long as the child maintains 
vigor, performs its functions normally, and is neither thin 
nor excessively fat there is no cause for alarm. 

GENERAL DEVELOPMENT. 

It is far more important that the child's flesh be firm 
and its muscles capable of vigorous action than that the 
child should be excessively fat. The fat and flabby in- 
fant is usually far from well. In such a child we should 
fear a delay in teething, or the gradual development of 
rickets or some other disease of the skeleton. We judge 
of the physical development of an infant by its weight, 
the firmness and elasticity of its flesh, its vigor, its color, 
and the evidences of physical happiness which it shows 
in the enjoyment of its food and sleep. 

THE NERVOUS SYSTEM. 

The growth of the nervous system of a child furnishes 
one of the most interesting and fascinating studies. At 



248 THE DEVELOPMENT OF THE CHILD. 

birth the brain and spinal cord are simply two masses of 
sensitive matter, capable of receiving very delicate im- 
pressions and very easily excited by sensations. There 
is no evidence that the newborn infant thinks, remembers, 
perceives, or has emotions. Nervous reflexes are present 
which are as active as in the adult. The senses are 
capable of excitement, and by repeated sensations from 
the same source the child soon locates the source of its 
food and learns to recognize in a manner its caretaker. 
The first nervous action of an infant is recognition, caused 
by the regular repetition of certain very necessary things. 
From this it can readily be inferred how important it is 
that the feeding and care of the child be conducted with 
regularity. Inasmuch as the nervous system develops 
by the regular repetition of several things upon which 
the child's life depends, we may see that the formation 
of regular habits is the beginning of the training of the 
child's brain and nerves. 

Parents usually recognize in a child evidences of intelH- 
gence before others can do so, or before there is good 
reason for believing that intelligence exists. Their 
behef should not be disturbed, however, as it does no 
harm and is to them a source of great interest and 
pleasure. Beyond the recognition of its food and care- 
taker the infant does not usually develop recognition 
until several months have passed. 

The faculty of sight is that most commonly observed, 
and that in which most persons recognize the first begin- 
ning of intelligence. The eye of the child sees, but the 
brain does not perceive. Images of external objects are 
received upon the eye, but the brain is not sufficiently 
developed to know what these sensations mean. The 
child will usually follow with the eyes a bright or glitter- 



MOTION. 249 

ing object, turning its head as the object is moved. It is 
probable that the sense of sight is among the first which 
is developed, as our memories usually go back in child- 
hood to something which was seen at that time. The 
sense of hearing does not seem to be developed promptly, 
nor does the olfactory sense, but the sense of taste, and 
the skin sense or touching sense, whereby the child 
appreciates cold or warmth, or rough or smooth sur- 
faces, are early formed. 

The Care of the Nerves. — In the development of 
the nervous system the obstetric nurse will find employ- 
ment for her powers of observation and judgment from 
the natural interest and sympathy which she feels for 
mother and child. The nurse will find herself usually 
growing fond of the child, and this will be a natural 
encouragement for its growth. What may be termed a 
proper mental atmosphere is as necessary for a child as 
for the happiness of an adult. Children are quick to 
feel the presence of ill temper, neglect, abuse, or any dis- 
turbing influence. Those who cannot control them- 
selves in the presence of the minor annoyances of life 
are not fitted to care for children. The nurse should 
remember that in forming proper habits for the child she 
is laying the foundation for its health and happiness. 
Her instinct will often guide her safely to appreciate its 
wants. There is no more interesting patient than a 
growing and developing infant, none which responds so 
quickly to ' good care, and none which does poorly so 
promptly as a growing child. 

MOTION. 

The first movements of an infant are apparently with- 
out purpose. The child's feet are prehensile as well as 



250 THE DEVELOPMENT OF THE CHILD. 

the hands, and the child will endeavor to grasp a 
finger with the toes and often to pull itself up from the 
bed. In grasping the finger it gradually passes to seizing 
various articles presented to it. Such are usually carried 
to the mouth, especially if there be irritation of the gums 
through the formation or extrusion of teeth. The child 
moves its limbs frequently when placed upon its back 
upon a favorable surface. If turned upon the abdomen, 
the child will endeavor to raise its trunk, and will some- 
times succeed in rolling over upon the back. Such 
exercise is very good for an infant, as it strengthens the 
muscles of the back. 

As regards the child's creeping or walking, if placed 
upon a blanket upon the floor it may be allowed to do 
whatever its strength permits. There should be no 
object nearby which the child can pull itself up by to a 
sitting or standing posture. It is, hoAvever, dangerous 
for grown persons to set a young child upon its feet, for 
the weight of the body may be too much for the infant, 
causing the legs to bend. An infant can be taught 
oftentimes to use the hands by a little intelligent super- 
vision, and thus dexterity can early be learned. 

That general condition of the nervous system 
known as temper can be seen in infants, as some children 
are cross and fretful, petulant and annoying, while others 
are good tempered and pleasant. Infants inherit the 
nervous peculiarities of parents. Usually, however, an 
infant is agreeable in proportion as it is properly nourished 
and well cared for. Any evidence of nervous disturbance 
should call for an examination of its physical condition. 
Here again in the formation of a temper the nurse cannot 
be too careful to insist upon regularity with the child. 
The words ** nervous " and *^ nervousness " should sel- 



PERIODS OF DEVELOPMENT. 25 I 

dom be used in speaking to mothers regarding their 
infants. It is a great misfortune for a child if it grows 
up under the expectation that it is to be a nervous child. 
In this connection the nurse will often have great diffi- 
culty in securing for the child freedom from intrusion. 
Those who visit the mother may desire to handle and 
inspect the child. It is quite customary to take an infant 
after it has been fed, and by jolting it violently and utter- 
ing loud and strange sounds to endeavor to soothe it to 
sleep. This disturbance the child resents by crying, and 
in the agitation its stomach is usually emptied of its last 
meal. 

PERIODS OF DEVELOPMENT. 

The development of a child is divided into periods 
which correspond with the various stages of nutrition 
present : The first is that which extends from birth until 
the coming of the first teeth. This is the period in which 
the child is usually, for some of the time at least, under 
the care of the obstetric nurse. During this time the 
child is without teeth, has little saliva, and its digestive 
organs are suitable for the digestion of milk only. The 
mistake of those who give to such infants foods and mixt- 
ures containing large quantities of starch and other sub- 
stances not naturally found in milk must be evident. In 
mother's milk the child finds all the nourishment neces- 
sary for this period, and when the child lacks this it is 
reasonable to give it the closest possible substitute for 
mother's milk. The child will go through its normal 
gaining and develop naturally upon mother's milk or its 
perfect substitute. The nurse should impress upon the 
mother or caretaker that this is the case. 

In the second period of nutrition the temporary teeth 
are coming. There is saliva in the mouth, and the child 



252 THE DEVELOPMENT OF THE CHILD. 

may be fed with milk combined with jellies or gruels 
made of wheat, oats, or barley. Such jellies or gruels 
are greatly superior for the feeding of the infant to pat- 
ented and prepared foods. They can be made by any 
intelligent person at very little cost. The third nutritive 
period extends during the time of the coming and going 
of the first temporary teeth to the gradual development 
and establishment oi the more firm and permanent teeth. 
During this period the child is fed upon milk, gruels, soft 
^g%, broths, soups, and a little of the mild and delicate 
sorts of meats, such as chicken, fish, or very tender beef. 
The duties of the obstetric nurse usually extend through 
the first period only, during the time of exclusive milk- 
feeding. She sometimes, however, has a child under 
observation through the first and second periods. 

DENTITION. 

At the sixth or seventh month it is usual for the 
first teeth to give evidence of their presence. These 
are the lower central incisors. Sometimes the upper 
central incisors appear at the same time or just 
before. The coming of a tooth occupies a consider- 
able period before the tooth can actually be seen. A 
perfectly healthy child shows little or no evidence of 
what is taking place. It may put objects into the 
mouth very readily or suck its thumb more vigor- 
ously, or bite harder upon the mother's nipple or the 
nipple of the bottle. The mucous membrane of the gum 
grows paler in color, and if the finger be pressed firmly 
down upon the jaw the gum feels hard under the touch. 
The tooth is usually found accidentally, and no one rec- 
ognizes the exact moment of its appearance. The next 
teeth after the lower central incisors are the upper central 



TO PROMOTE DEVELOPMENT. 253 

incisors. They are usually expected at about the eighth 
to the twelfth month. At nine months the healthy child 
may have the following teeth protruding through the 
mucous membrane of the gums : two lower central in- 
cisors, four upper incisors. 

The common belief that children must necessarily be 
sick and ailing when the teeth come is a very serious 
error. In well-developed and properly fed children it is 
usually impossible to note the coming of the tooth. If 
the child is ill fed, badly nourished, and excessively 
nervous, its bad health may be made worse and much 
more noticeable by the slight irritation of teething. 
When a child is getting its teeth in the first period and 
is fretful and ill, a physician must be sent for, who will 
thoroughly examine the child, and find some valid reason 
for the child's discomfort. If it be fed and properly cared 
for, the child will usually go on with its teething with 
but very little disturbance. 

TO PROMOTE DEVELOPMENT. 

A very interesting question arises, " What can the 
obstetric nurse do to promote the healthy growth and 
development of the child ? " We believe that there is 
no more important part in the province of nursing than 
this, to aid in the establishment of sound health. This 
the nurse can greatly facilitate by regularity in the care 
of the child ; by protecting it from unnecessary interfer- 
ence and from annoying and worrying attentions, and by 
strict cleanliness and neatness in every detail connected 
with the child. The keeping of a suitable record and 
the reporting at regular intervals of the performance of 
the child's functions and its normal growth are most 
important. Too much is often left to the nurse in this 



254 THE DEVELOPMENT OF THE CHILD. 

regard, and if the child is apparently doing well the 
doctor does not ask for the information which he should 
have. His record should show the weekly weight and 
condition of each infant under his charge, with the char- 
acter and composition of its food, and the details of any 
method of treatment employed. The nurse should teach 
the mother to weigh the child regularly and to keep the 
proper records and make the proper report. 

CARE DURING TEETHING. 

During the time when the coming of teeth is appre- 
hended the nurse must remember to be strictly careful 
that nothing which is unclean gains access to the child's 
mouth. If the gums are swollen and sensitive, a spray 
of cool or cold water is often a great comfort. Where a 
tooth can be detected beneath the gum, if the finger be 
thoroughly washed and dipped in ice water, the child 
will usually allow the nurse to rub very gently but firmly 
down upon the point of the coming tooth. Sometimes a 
bit of ice wrapped in soft, clean old linen may be used to 
make gentle pressure for a short time upon the swollen 
gum. Physicians sometimes prescribe lotions or other 
applications which the nurse may apply upon the tip of 
the finger or upon soft linen in accordance with his 
directions. Usually very simple precautions are all 
that are required to keep the mouth in good condition 
during this time. Sometimes children have excessive 
fluid in the mouth at the coming of the teeth, and this is 
best remedied by pinning about the neck bibs or clean 
handkerchiefs, to keep the underclothing neat. 

EXERCISE AND AIR. 

The muscular development of an infant can best be 
promoted by the nurse by the regular bathing of the 



EXERCISE AXD AIR. 255 

child, with massage after the morning bath. Abundant 
fresh air, suitable clothing, and in addition to this proper 
food, are most necessary. Young children during the 
winter should not be taken upon the streets, but may be 
aired in an upper room by clothing the child properly 
and then opening the windows of the room. In mild 
weather the child should be out of doors as much as 
possible. Where sunshine can fall upon the child it is 
most advantageous. Nurseries should be sunny, clean 
rooms, with* abundant ventilation and without plumbing 
connecting with the sewer. If a carriage is available, 
the child may go out in the nurse's arms during proper - 
weather. Its own baby-coach may be used in yards and 
upon piazzas with the child suitably clad. The clothing 
should be so arranged as not to interfere in any degree 
with the child's movements. Skirts should not go much 
below the feet, as few skirts as possible should be worn, 
and the child should be encouraged to move its limbs. 
Nurses are often obliged to overcome strong prejudice 
against fresh air on the part of mothers, as they fear lest 
the child should take cold. They should remember that 
the absence of fresh air and the resulting weakness which 
follows easily predispose an infant to taking cold and to 
disease of the lungs. 



PART II. 

Gynecologic Nursing. 



INTRODUCTION. 



DEFINITION. 



This branch of nursing has to do with those conditions 
of ill health in women in which the pelvic organs are 
concerned, but in which disease does not arise from 
pregnancy, parturition, or the puerperal state. As the 
majority of diseases among w^omen are connected with 
pregnancy or parturition, it will be seen that the field of 
gynecologic nursing is a narrow one. As much of the 
treatment employed is of a surgical nature, it is more a 
surgical specialty than a separate and distinct department 
of medicine. 

CAUSES OF DISEASE. 

In many cases of disease among women some consti- 
tutional disorder inherited or acquired is the cause of ill 
health. Anemia or failure to excrete properly produces 
a depraved condition of the nervous system which makes 
natural functions painful in their performance. In other 
cases a distinct pathologic lesion is the cause of disease, 
as seen in tumors and foreign growths in the pelvis. In 

256 



THE MANAGEMENT OF PATIENTS. 257 

other patients deformity or lack of development in the 
pelvic organs brings about ill health. 

PECULIARITIES OF PATIENTS. 

As many of these cases are chronic in nature and long 
continued, the disease exerts a profoundly depressing 
effect upon the patient's mind and disposition. Such 
patients are often melancholy and suffer severely from 
mental depression. Others are exceedingly nervous, 
timid, and apprehensive, exaggerating discomfort and 
suffering. In other cases, however, a patient endures for 
years considerable distress with surprisingly little com- 
plaint. 

THE MANAGEMENT OF PATIENTS. 

Nurses sometimes find these cases tr^dng to care for, 
because of the mental depression of the patient. While 
it is difficult to satisfy fears and longings in many 
instances, still in others the nurse's services are highly 
appreciated and the patient cooperates most cheerfully in 
the treatment employed. The nurse must not be sur- 
prised at manifestations of hysteria, or any other of the 
abnormal actions which chronic nervous disease brings 
about. She must not be deceived b}- them ; and while 
not offending her patient, she must take care to observe 
accurately the patient's symptoms and conditions. She 
must strictly preser\x the patient's confidence, for many 
women excessively disHke to have the ailments peculiar 
to their sex narrated to other persons. In some cases, 
however, the patient becomes so mentally disordered 
that she delights in narrating the operations to which she 
may have been subjected. While the nurse may give 
comfort and encouragement by kindness and sympathy, 
17 



258 INTRODUCTION, 

she must maintain especially her individual firmness and 
self-control. Obtaining clear and positive orders from 
the physician in charge, she must carry them out kindly 
but unflinchingly. She must respect the patient's deli- 
cacy of feeling in every possible way by avoiding un- 
necessary exposure and by showing uniform deference 
and civility. She must be absolutely clean in herself and 
in all objects which she uses about the patient. If she 
is business-like, methodic, and energetic, she will often 
find her difficulties much less than the querulous nature 
of the patient had led her to fear. A patient once 
remarked regarding a nurse, that when anything was to 
be done, the nurse went ahead and did it so promptly 
that the patient had not time to decide whether the 
treatment carried out was painful or distressing or 
depressing. This may serve as a useful hint in the 
management of these cases. 



CHAPTER I. 
THE EXAMINATION OF PATIENTS. 

PREPARATION FOR EXAMINATION. 

In all critical cases in which difficulty is experienced 
in arriving at a positive diagnosis the physician will have 
his patient prepared for an examination. The bladder 
and rectum should be emptied if necessary by catheter 
and by an enema. The patient's clothing must be so 
arranged that corsets and other constricting material are 
removed. One thickness of soft linen over the body 
seldom interferes with an examination and is usually 
more comfortable for the patient. As women are often 
apprehensive regarding examinations, the nurse should 
encourage the patient as much as possible that such a 
procedure need not be painful and should certainly not 
incur danger. 

AN OFFICE EXAMINATION. 

A complete and thorough examination of a gynecologic 
patient is best made in the office of a physician or at a 
hospital. At either place a suitable table is available 
which allows the patient to be put readily into various 
postures and where a good light, instruments, cotton or 
gauze are all at hand. Various tables are in use in 
physicians' offices which can be so turned upon one or 
other side or raised or lowered as to put the patient in 
various postures. The feet are supported in stirrups or 
foot-rests especially adapted to the purpose. In arrang- 

259 



26o THE EXAMINATION OF PATIENTS. 

ing a patient upon a table for examination the nurse 
should have at hand a clean sheet, half the size of the 
ordinary sheet for a double bed ; to support the patient's 
head she should have several small and rather firm 
pillows. For some purposes the head must be placed 
higher than for others, and hence the need for several 
pillows. Tables are so arranged that the patient can step 
upon a foot-board and turning with her back to the table, 
the nurse can so lift the patient's skirts that they will be 
out of the way. The patient should then sit and then lie 
upon the table, assuming the posture which the nurse 
desires. She should be covered by the sheet during the 
examination. The physician will require the nurse to 
assist in putting the patient in various postures or to 
assist in manipulating the table as may be necessary. 

Instruments. — Various instruments may be em- 
ployed, and these must be prepared by washing them 
in soap and hot water, and placing them in an antiseptic 
solution, or by sterilizing them by boiling, as the physi- 



FiG. 65. — Retractor, speculum, tenaculum-forceps, scissors, scalpel, blunt scissors, 
dissecting-forceps, hemostats, needles, needle-forceps, gauze-forceps, curet. Descrip- 
tion begins from left to right of picture. 

cian may direct. Gynecologists usually have sterilizers 
in their offices in which instruments can quickly and 
readily be prepared. The nurse must be careful that 
solutions in which instruments are placed are warm, but 
that the instruments are not too hot. 



EXAMINATION IN PRIVATE HOUSES. 26 1 

Antiseptic Solutions. — Physicians often select anti- 
septic solutions which serve as lubricants as well. Among 
these, lysol is especially convenient in i per cent, solu- 
tion. Others use warm Castile soapsuds, and others use 
hot water only, lubricating instruments with ointments 
prepared for the purpose. 

Cotton or Gau^e. — To wipe away secretion and 
cleanse parts for examination pledgets of cotton or 
small pieces of sterile gauze should be in readiness. 
There should also be a receptacle for these when soiled, 
and they should be burned as soon as possible after use. 

I/ight. — In some physicians' offices a gas-light with 
a condensing lamp is available for examinations. In 
others a window impervious to observation is used. 
During such an examination it is the duty of the nurse 
to prepare the patient, place her in proper posture, to 
clean or sterilize the doctor's instruments, and to have at 
hand antiseptic solutions, lubricants, gauze or cotton as 
he may desire. In some cases a douche is given before 
an examination, and in other cases after the examination. 
When the physician is through with the patient the 
nurse must see that she has not been soiled by oint- 
ments or antiseptics used during the examination. 

EXAMINATION IN PRIVATE HOUSES. 

It is often impossible for a patient to go to the office 
of the physician, and it may be necessary to conduct the 
examination in the patient's house. The nurse must im- 
provise for the purpose a table or so arrange a bed that 
it will be suitable for the patient's use. If a table is 
necessary, a clean kitchen -table covered with blankets 
and sheet is usually convenient. It should be so placed 



262 THE EXAMINATION OE PATIENTS. 

that a good light will be available. As such a table is 
without supports for the feet, the nurse must rely upon 
the services of some one besides herself, or she may hold 
the patient's limbs while in the dorsal position by the use 
of a sheet folded in its longest way, passed about the 
patient's shoulders, and tied about the legs below the 
knees. If it is desired to raise the pelvis, folded 
blankets or a cushion may be placed beneath the hips 
of the patient, thus elevating the pelvis while the pil- 
low is taken from beneath her head, allowing the 
shoulders and head to be low. If a bed is to be em- 
ployed, it should be as high a bed as is available, the 
mattress should be firm, the covers should be removed 
from the bed, and the bed used as a table, the patient 
being covered with a sheet. 

In a private house the clothing of the patient is readily 
arranged. A night-dress, dressing-wrapper, stockings, 
and slippers make a very convenient combination. Un- 
less the physician orders an antiseptic solution to be in 
readiness, the nurse must rely upon hot water in abun- 
dance. Castile soap should be selected in preference to 
highly scented soaps. If a lubricant is required, olive 
oil may be used, or vaselin or cold cream. The latter, 
however, may have been employed for some domestic 
use, and hence are not usually as clean as olive oil. If 
the physician uses instruments in his examination, he 
may require several basins, the ordinary toilet basin 
being available for the purpose. If the physician does 
not bring gauze or cotton, and there is none available, 
the nurse may use old linen torn into small pieces and 
boiled if she has an opportunity to prepare it in this 
way. Before an examination the patient should be in- 
structed to empty the bladder, and the bowels should 
have been emptied by medicine or by enema. 



JNSTRUMEiXTS FOR EXAMINATION. 



263 



DESCRIPTION OF INSTRUMENTS FOR EXAMINATION. 

Specula. — Specula are the instruments most com- 
monly used for this purpose. They are adapted to open 
the birth-canal of the patient, giving opportunity to ex- 




f'lG. 66. — Sims' speculum. 



amine the womb by sight. The speculum most commonly 
employed is Sims' (Fig. 66). This must be held by the 




Fig. 67. — Bivalve speculum. 



nurse or by the physician during the examination. Other 
specula are composed of two or more blades or portions 
so arranged that the instrument is introduced when 
closed, and the blades then opened to dilate the passage. 



264 



THE EXAMINATION OF PATIENTS. 



Other specula are arranged to be self-retaining by the 
attachment of a weight or small pail to receive douche- 
water or discharges. Occasionally cylindric specula are 
employed. Nickel-plated steel is the material of which 
specula are usually made. Such are tarnished by bi- 
chlorid solutions, but are not affected by carbolic acid, 
creohn, lysol, or boric acid. Aluminum specula are sel- 
dom used, and glass specula are very rarely employed. 
Hard rubber is sometimes used in making these instru- 





FiG. 68. — Edebohls' self-retaining 
speculum. 



Fig. 69. — Fergusson's 
speculum. 



ments, but it has the objection that it cannot be boiled 
without becoming soft. 

In addition to specula, the physician may employ for- 
ceps for grasping the- neck of the womb and drawing it 
down. These are tenaculum-forceps. They are of two 
blades, sharply pointed at the extremities and sometimes 
closing with a lock. Uterine dressing-forceps are also 
used, for wiping away discharges with gauze or cotton, 
or for making applications of medicines. Scissors are 



EXAMINATIONS UNDER ETHER. 265 

needed in cutting gauze, and in rare cases in removing 
small bits of tissue for microscopic examination. When 
an examination is made of the kidneys and ureters cath- 
eters of various sizes are used. Piston-syringes or 
syringes especially constructed for withdrawing fluids 
from the kidneys, ureters, bladder, or uterus, are em- 
ployed in some examinations. Specula especially de- 
signed for the rectum are frequently used, and resemble 
those constructed for the examination of the womb, but 
differ in size. Sounds or probes are sometimes, although 
not often, employed. 

In some cases electric apparatus is used in such ex- 
aminations. The electric light is exceedingly convenient 
for office use, and some forms of it have been especially 
adapted for the investigation of the bladder. Cysto- 
scopes are instruments designed for examination of the 
bladder, and are cylindric metal instruments of graduated 
sizes. 

EXAMINATIONS UNDER ETHER. 

In doubtful cases in which especial difficulty attends 
a diagnosis it is customary to examine the patient under 
ether. The nurse who assists at such an examina- 
tion should provide towels or napkins upon which the 
ether may be given, should care for the patient after the 
administration, should have ready what is necessary in 
case of vomiting, and should perform the duties which 
a nurse usually does in cases in which an anesthetic is 
given. While a nurse should not accept the responsi- 
bility of giving an anesthetic, she may \{ desired continue 
the administration of ether at the doctor's request after 
he has anesthetized the patient. 

Duties of Office Nurse. — If a nurse has charge 
of a doctor's office and instruments, she must remember 



266 THE EXAMINATION OF PATIENTS. 

the great necessity for absolute cleanliness with all in- 
struments and appliances. It is usually best not to ster- 
ilize instruments for examination after they have been 
used, but to wash them very thoroughly with soap and 
hot water and to dry them very carefully. Jointed in- 
struments should be taken apart and dried if possible. 
If the joints cannot be taken apart, the nurse may request 
the physician's permission to use sterile or carbolized oil 
or glycerin to prevent rusting and the accumulation of 
dirt. The nurse who has charge of office instruments 
should give the physician notice when instruments 
require repair or replating. Specula are readily injured, 
and may be ruined if the plating is not frequently re- 
newed. Lysol is especially useful in disinfecting instru- 
ments, preserving their plating, and preventing them from 
rust. Well-made rubber articles are not attacked by 
lysol. Instruments should be boiled in 2 per cent, lysol " 
to disinfect them thoroughly. 

An office nurse is responsible for the office linen, 
which should be absolutely plain, of good quality, and 
perfectly clean and neat. She is also responsible for the 
cleanness of the examining-table, including its drawers 
and appliances, for the good condition of the sterilizing 
apparatus, the instruments and appHances, and for the 
good condition and sufficient quantity of the drugs or 
dressings used in examinations. But her duty will be 
half done if she confines herself to these points only. 
By the neatness and plainness of her uniform, including 
her cap, by her own exquisite neatness, and her quiet, 
sympathetic, and intelligent manner, she can very much 
lessen the influence of a trying ordeal for the patient. 
She must be skilful in avoiding discomfort and pain, and 
very discreet in her remarks. Under no circumstances 



DUTIES OF OFFICE NURSE. 267 

should she repeat knowledge gained while assisting a 
physician in the examination of a patient. As absolute 
quietude must be observed in some important cases, the 
nurse should avoid squeaky shoes and noisy clothes. 
It is well for her to wear felt slippers in office-work, and 
to have her clothing as little obtrusive as possible. As 
the physician will often examine the entire trunk of the 
body, he will listen to the heart, and would be much 
annoyed by a loud and disturbing noise. 



CHAPTER II. 

POSTURES OF THE PATIENT FOR EXAMINATION 
AND OPERATION. 

DORSAL OR LITHOTOMY POSITION. 

This is the most usual posture employed for pelvic 
examinations and for operations upon the cervix, vagina, 
pelvic floor, and perineum. The patient is placed upon 
the back at the edge of a bed or table. The feet may be 




Fig. 70. — Improvised leg-holder with twisted sheet (Hirst) 



allowed to rest upon the edge of the surface on which 
the patient is lying, or the legs and feet may be raised 
several feet from the bed. In the first position the 
patient may edge away from the examining physician by 

268 



SIMS' POSITION. 269 

pushing with her feet if the examination is painful. If 
the feet and legs are raised from the bed, she is not so 
likely to do this. To support the legs and feet when 
raised, two assistants may be employed, or a folded sheet 
may be passed behind the shoulders and tied around the 
legs (Fig. 70), or the feet and ankles may be supported 
by Edebohls' stirrups (Fig. 49). In some cases of dorsal 
position it may be desired to raise the pelvis, allowing the 
pelvic organs to gravitate downward and backward. 
This is accomplished by placing beneath the patient's 
hips and buttocks a folded blanket and sheet or a firm 
pillow. In all examinations the trunk of the patient 
should be free from constricting clothing and covered 
preferably by one thickness of linen. The thighs should 
be wrapped in towels or sheets, and the legs and feet 
covered by stockings. In hospital practice it is usual to 
employ leggings made especially for the purpose, which 
can be sterilized, and which are drawn over the feet, legs, 
and thighs. 

SIMS' POSITION. 

In this posture the patient is placed upon her left side, 
her right thigh and leg strongly flexed and carried up- 
ward and sHghtly forward, the left arm placed behind 
her, the head turned upon the left side. The hips and 
buttocks are at the edge of the bed or table. It is often 
best to use no pillow for the head in this posture, al- 
though if the patient prefers it she may use a low pillow 
(Fig. 48). 

The object of Sims' position is to enable the physician 
to open the vagina readily with Sims' speculum, drawing 
back the pelvic floor and making the womb easy of 
access. To accomplish manipulations with the patient in 



270 



POSTURES OF THE PATIENT. 



this posture, the nurse is required to hold the speculum 
after the physician has introduced it. She should stand 
with her back toward the patient's head, grasping the 
upper blade of the speculum with the right hand, taking 
care to hold it exactly as the physician directs. With the 
left hand she should raise the upper buttock of the patient, 
drawing it upward and backward. The nurse should be 
careful that she makes proper pressure with the point of 




Fig. 71. — Sims' speculum, introduced and held by a nurse (Hirst). 

the speculum which is internal. Unless caution is ex- 
ercised, she may unconsciously allow the speculum to 
slip, defeating the doctor's efforts at examination. In 
Sims' position the patient's body and limbs may be cov- 
ered in any convenient manner, it being necessary to 
expose only the region of the body to be investigated. 



TREXDELENBURG POSITION. 2/ 1 

KNEE=CHEST POSITION. 

In this posture the patient rests upon the knees and 
chest (Fig. 7). Her skirts should be raised above the 
knees, and she should then kneel upon the edge of the 
bed or table. She should then incline the body forward 
until the chest rests upon the bed, using a pillow if de- 
sired. Many patients when asked to assume this position 
attempt to he flat upon the abdomen. This is incorrect, 
and the nurse must see that the patient keeps the thighs 
flexed and the pelvis high. With the patient in this posture 
the pelvic and abdominal viscera tend to gravitate upward 
and forward if the vagina be opened. To accomplish 
this, the physician may introduce a speculum admitting 
air, or he may draw the pelvic floor upward and back- 
ward by the finger. This position is much used in cases 
of backward displacement of the womb, in replacing the 
uterus and applying pessaries. The patient is often asked 
to assume this posture at night or morning. The nurse 
may be required to teach her the exact posture desired. 
The nurse must carefully place the patient in the correct 
posture, emphasizing the necessity for keeping the hips 
high and the chest low. In some cases the physician 
may ask the patient to introduce a tube into the vagina 
before assuming this posture, so that air may enter and 
the pelvic viscera move in the desired direction. With a 
little patience this posture may be assumed spontaneously 
by a patient and retained for from ten to twenty minutes. 

TRENDELENBURG POSITION. 

This posture is usually employed in abdominal section. 
It is rarely used in examinations under an anesthetic. In 
this posture the patient lies upon her back, her legs flexed 



272 POSTURES OF THE PATIENT. 

at a right angle with the thighs and hanging over the 
edge of the table. The table upon which the patient lies 
is then raised so that the hips of the patient are greatly- 
elevated, while the head and shoulders remain low. The 
degree of elevation is varied with the needs of the case. 
To retain the patient in this position, the ankles and 
knees must be fastened to the foot of the table, while it 
is desirable that supports be employed for the shoulders. 
When the patient is placed upon the table her legs should 
be fastened to the lower or folding piece by several turns 
of a broad soft bandage. A loop of similar bandage 
should be passed about the ankles, and when the patient 




Fig. 72. — Trendelenburg position. 

has been raised to the desired height this bandage should 
be fastened to the lower portion of the table. If these 
precautions are not taken, the patient may slip down 
during the operation, very seriously embarrassing the 
operator. To avoid injury to the knee-joints, the nurse 



TRENDELENBURG POSITION. 273 

who places the patient in position must see that the legs 
are completely but easily bent over the edge of the table. 
Care must also be taken that the patient's arms do not 
drop down beneath the raised portion of the table. 
Cases are on record in which serious injury to the arms 
has resulted from such an accident. Care should also 
be exercised that the neck of the patient is not bent too 
sharply. The head must rest easily, turned upon one side, 
so that no obstruction to breathing is afforded. In using 
the Trendelenburg posture it is usually desired to vary 
the degree of elevation during the operation. In many 
tables adapted for the Trendelenburg posture shoulder 
braces are used to receive the weight of the patient and 
to avoid interference with breathing. Some tables are so 
arranged that the entire table may be raised at the foot 
whenever the operator chooses. To keep the patient 
from sliding down on the table, shoulder-pieces are used, 
and the patient's entire body can thus be readily inverted. 
The nurse in charge should make herself familiar with 
the workings of the table, so that she can raise or lower 
the patient quickly and without delay. 

In an emergency when no table is available the 
Trendelenburg position may be improvised by using a 
large rocking-chair from which the legs and rockers have 
been taken. If the chair be turned over so that it rests 
upon the extremity of the back and the front edge of 
the seat, it forms an inclined plane upon which the pa- 
tient may be placed. The chair must be covered with 
blankets to make the patient thoroughly comfortable. 

Many tables arranged for the Trendelenburg posture 
have a drainage apparatus and pan in connection with 
them. The nurse should see that this is in order before 
the patient is placed in position, and that there is no 
obstacle to the proper flow of fluid. 

18 



274 



POSTURES OF THE PATIENT. 



STANDING POSITION. 

Patients are occasionally examined while standing. 
One foot is to be raised and placed upon a stool or pile 




Fig. 73.— Erect position with the right foot resting on the round of a chair (Ashton). 

of books, while the physician makes his examination. 
This posture is not often used, but may be required. 

SQUATTING POSITION. 

The patient is occasionally asked to assume the squat- 
ting posture, straining as if in the act of defecation. This 
is done to show prolapse of the walls of the vagina if 
such be present. 



POSITION BENDING FORWARD. 2/5 

POSITION BENDING FORWARD. 

It sometimes happens that the physician wishes to 
relax the anterior wall of the abdomen while the patient 
is in the sitting or standing posture. To do this, she 
places her hands upon the back of a chair placed in front 
of her, or upon the shoulders of a nurse, and leans the 
body strongly forward while either sitting or standing. 
The physician then palpates the abdomen with the 
abdominal walls relaxed by this posture. 



CHAPTER III. 
LOCAL TREATMENT.— PES5ARIES. 



Fig. 74.— a, uter- 
ine applicators ; 6, 
same in handle. 

276 



LOCAL TREATMENT. 

By this is meant the appHcation to the 
womb or to the tissues about the vagina 
of medicines. Those most frequently em- 
ployed are tincture of iodin, ichthyol, 
glycerin, boric acid in powder or solution, 
and occasionally calomel or some other 
form of mercury. These medicines are 
appHed in ointments or in liquid form by 
means of absorbent cotton, in supposi- 
tories, or in capsules of gelatin placed 
within the vagina and allowed to melt. 
Such treatment is usually carried out at a 
doctor's office or at the house of a patient, 
when the assistance of a nurse may or 
may not be required for this work. Such 
treatment is much less practised now than 
formerly, as it has not proved very suc- 
cessful in the treatment of disease. 

The nurse should prepare for such treat- 
ment the instruments required, which are 
a speculum, dressing-forceps, scissors, and 
applicators (Fig. 74). By the latter are 
meant thin rods of whalebone or metal, 
about which absorbent cotton in a thin 
sheet can be wrapped. This is then dipped 
into iodin or glycerin and carried into the 



PESSARIES. 277 

neck of the womb. These instruments should be steril- 
ized by boiling, and placed in an antiseptic solution in a 
suitable tray ready for use. The nurse must also have 
ready a lubricant and clean towels, and a receptacle for 
soiled cotton, with small bits of sterile cotton or sterile 
gauze in abundance. 

Posture. — The postures usually employed for this 
treatment are the dorsal and Sims'. The nurse should 
take care to protect the patient from soiling with medicines 
employed, by wrapping the limbs in towels or sheets, 
and by placing cotton or towels beneath the perineum. 
As some of the medicines used stain linen badly, the 
nurse must be careful that the patient's undercloth- 
ing does not become soiled. Instruments employed in 
this treatment should be cleaned as soon as possible 
after use with a strong alkaline soap, to remove medicine 
which may adhere to them. Soiled cotton or gauze 
should be burned as soon as possible. 

Tampon. — A tampon, or pledget, is a small mass of 
cotton, wool, or gauze inserted within the birth-canal, 
and allowed to remain there to make pressure or to con- 
vey medicine to produce a continuous action. To pre- 
pare a tampon, cotton or wool is formed into a sheet a 
half inch thick and several inches square, depending 
upon the size required. The tampon should be suffi- 
ciently small to pass readily through the speculum 
which the physician employs. The corners of the sheet 
of cotton or wool are then brought together, and the 
whole is twisted into a ball having the corners as a stem. 
About this stem soft white twine, sterilized by boiling, 
should be wound tightly several times and firmly tied. 
Such a tampon is dipped in glycerin or other medicine, 
introduced within the vagina, and allowed to remain. It 



2/8 LOCAL TREATMENT. — PESSARIES. 

is removed by pulling upon the string, which should be 
left sufficiently long to have the end protrude slightly 
from the vagina. A tampon cannot remain in place 
very long without causing irritation and disease. Ac- 
cordingly, the patient must be carefully instructed to 
remove the tampon at the time ordered. She must pull 
very gently downward and slightly backward, when 
little difficulty will be experienced. The cotton tampon 
is usually employed for the application of glycerin, ich- 
thyol, or some other medicine. 

Carded Wool Tampons. — In cases in which it is 
desired to make gentle pressure for some time to correct 
a faulty position of the w^omb, carded wool is made into 
various shapes, sterilized, anointed with an antiseptic 
ointment, inserted into the birth-canal, and allowed to 
remain for several days. Special care must be taken in 
the making and sterilization of such tampons that they 
be absolutely clean. Ointments of boric acid, ichthyol, 
lanolin, or other medicines are usually employed with 
such tampons. 

Vaginal Capsules. — In some cases gelatin capsules 
containing carded wool are medicated with a desired 
drug, inserted within the vagina, and allowed to remain. 
The heat of the body melts the gelatin, and the medi- 
cated wool is left in contact with the parts. It is some- 
times convenient to dip these capsules in warm water 
just before inserting. They are removed by pulling 
upon a string which is attached to the wool within the 
capsule. If a nurse is asked to medicate such a capsule, 
she will find it composed of two parts, one sliding over 
the other. By slipping these parts asunder she can put 
upon the wool glycerin or any other medicine desired. 



FESSARIES. 



279 



PESSARIES. 

Pessaries are supports for the womb, made of rubber, 
and usually of hard rubber. They serve the place of a 
crutch or of a truss, and are employed until the patient 
can grow strong enough to maintain the womb in proper 
position without their aid. If this does not happen, the 
condition for which the pessary 
was introduced is usually treated 
by some form of operation. To 
prepare a pessary for introduction 
by the physician, the nurse must 
remember not to boil a rubber 
pessary. Hard-rubber pessaries 
are so softened by boiling that 
they lose their shape. If the fig. 75.-Spirai pessar3^ 
physician desires to bend a hard-rubber pessary, he may 
soften it in boiHng water or over an alcohol lamp. Pes- 





FiG. 76. — Pessaries for retroversion : a, Hodge pessary' ; b, Smith pessary ; c, Thomas 
pessary (Penrose). 

saries should be washed thoroughly with soap and warm 
water, rinsed, and put into an antiseptic solution until 



28o LOCAL TREATMENT. — PESSARIES. 

used. They are of various shapes and kinds according 
to the condition for which they are used in treatment. 

Introduction of the Pessary. — To prepare a 
patient for the introduction of a pessary, the nurse should 
make the patient's clothing perfectly loose about the 
waist. The bladder should be emptied, and the bowel if 
convenient. The patient will be placed in such a position 
as the physician desires, usually the dorsal or the Sims'. 
There may be needed a Sims' speculum and tenaculum- 
forceps. Occasionally other instruments are used. A 
lubricant is necessary, and the pessary and instruments 
should be made thoroughly clean. The patient's Hmbs 
should be suitably wrapped and protected during the 
introduction of the pessary. During this the nurse may 
sometimes assist the physician by holding his instruments 
or by some other slight manipulation. When the pessary 
has been inserted the physician may change the patient's 
posture, often putting her in the knee-chest posture for a 
few moments. The nurse should have this in mind, and 
should have arranged the patient's clothing so that she 
can be readily shifted, and have the table or bed suitably 
prepared. 

Caution to Patients. — The nurse as well as the 
physician should caution patients that a pessary may do 
harm as well as good. If the patient feels better after 
the introduction of the pessary, it is doing good. If, 
however, she has pain, with a considerable discharge of 
mucus and interference with the bladder and rectum, the 
pessary is doing harm. She must then go to the doctor 
at once. The patient must not be frightened if the 
pessary comes out. Cases are sometimes seen in which 
it is very difficult to fit a pessary so that it will be 
retained. The patient may find the end of the pessary 
protruding from the vagina after she has emptied the 



FESSAEIES. 2S I 

bowel or bladder. While this is annoying and possibly 
terrifying, there is no danger connected with the spon- 
taneous expulsion of the pessary. 

Removal and Readjustment of the Pessary. — 
When the pessary has ceased to be needed it is removed, 
and the patient allowed to go without, or another better 
suited to her condition is inserted. The duties of the 
nurse are the same as those already described. The old 
pessary should be wrapped in paper so soon as removed 
and burned. Nurses must be careful to warn patients 
that while wearing a pessary they require at least one 
vaginal douche daily. The physician will prescribe what 
medicine, if any, should be employed in the douche. 
Borax or boric acid is most frequently ordered. If 
required, the nurse may teach the patient how to take 
the douche, remembering that in the introduction of the 
douche-tube the tube should be pressed backward toward 
the rectum, to avoid interfering with the pessary. The 
nurse is sometimes asked by the patient to remove the 
pessary. She should not do this without the physician's 
consent and request. To accomplish this manipulation, 
the patient should be placed upon her back at the edge 
of the bed or table, her feet supported on chairs. The 
nurse, having thoroughly washed her hands and lubrica- 
ted the index finger of one hand with soap, should insert 
it within the vagina, passing it upward behind the pubic 
bone. She will then feel the anterior bar of the pessary ; 
she should hook her finger over this bar and then pull 
gently downward and backward, turning the pessary 
slightly sidewise upon its edge, when it will usually come 
out without difficulty. If the effort gives the patient 
considerable pain, and if the nurse cannot readily accom- 
plish the removal of the pessary, she should cease her 
efforts and report to the physician in charge. 



CHAPTER IV. 

DOUCHES. 

A VERY important part of the nurse's duties in the 
care of gynecologic cases consist in the giving of douches. 
These may be vaginal, intestinal, or vesical. In the first, 
fluid is injected into the vagina affecting the neck of the 
womb and vaginal tissues ; in the second, the mucous 
membrane of the bowel is treated by injections ; while in 
the third, the mucous membrane of the bladder is 
douched. 

VAGINAL DOUCHES. 

Fluids used for this purpose are water only, astringent 
solutions, and antiseptic solutions. Water is employed 
for cleanliness or to convey heat. 

The Hot Vaginal Douche. — This is a most valu- 
able method of treatment, but must be given in the cor- 
rect manner to have a good effect. The temperature of 
the water must be ascertained by a thermometer. It should 
be from iio° to 120° F. At least a gallon is needed for 
each douche. The water must be applied continously to 
the parts treated. The patient should lie recumbent in 
the dorsal position. If she assumes a crouching or sit- 
ting posture, the water runs away as quickly as it is in- 
jected, doing little good. From fifteen to twenty min- 
utes are needed for the giving of a hot douche. The 
nozzle must not be of metal, as such may become so 
heated as to burn the patient. The nozzle or tube must 
282 



VAGINAL DOUCHES. 283 

be of hard rubber or of glass (Fig. 'jf). It is best for 
the patient to remain recumbent for some time after the 
douche, to secure its best effects. If the patient has no 




nurse and is obliged to take the douche alone, she may 
do so in an ordinary large bath-tub, in which she can 
recline while taking the douche. 

Astringent Vaginal Douches. — Astringent vagi- 
nal douches are those of solutions of alum or combina- 
tions of gallic and tannic acids. The exact strength of 
these will be prescribed by the physician in charge. Zinc 
sulphate is also used in solution for astringent douches. 
The temperature of these douches is usually from 85° to 
90° F., and the quantity from two quarts to one gallon. 

Antiseptic Vaginal Douches. — These are given 
for the purpose of destroying bacteria in the mucous 
membrane of the vagina. Solutions of mercuric chlorid 
are very commonly used for this purpose. If there is 
much mucous secretion, the nurse must remember that 
bichlorid cannot destroy germs contained in mucus, as 
the bichlorid combines with the mucus to form an insolu- 
ble compound. The mucous membrane must be cleansed 
in these cases by a douche of soapsuds followed by warm 
water. If the mercurial douche be then administered, it 
will have its antiseptic effect. The strength of bichlorid 
douches must be carefully regulated by the physician in 
charge, i : 4000 is a strength often employed. As mer- 
curic chlorid is a powerful poison, vaginal douches may 
poison the patient. Symptoms of this condition would 



284 DOUCHES. 

be a bloody and mucous diarrhea, salivation, variation in 
temperature and pulse, and should the case become 
severe, finally prostration and death. Mercuric chlorid 
combines with mucus to cloud or coat douche-tubes. 
This must be removed by boiling the tubes in a solution 
of soda. Mercuric chlorid is usually sold in tablets 
readily soluble. If furnished to the nurse in solution, 
she must be careful to observe that there is no precipi- 
tate at the bottom of the bottle. This would be undis- 
solved bichlorid, and might be a source of danger. The 
addition of common salt and the shaking of the bottle 
vigorously will usually dissolve any precipitate. 

Carbolic-acid douches are not used as frequently as 
formerly, because creolin and lysol have taken their 
place. Solutions of carbolic acid are very dangerous if 
the acid is not perfectly dissolved. If the nurse sees at 
the bottom of the bottle globules or drops of a brownish 
oily substance, the carbolic acid is undissolved and may 
fatally burn the patient. To such a solution must be 
added sufficient glycerin or alcohol to make the solution 
thoroughly clear after the bottle has been shaken. Car- 
bolic acid is usually employed for douches in strength 
of I per cent. Symptoms of poisoning by this drug are 
scanty, smoky urine, burning sensation in the vagina, 
and the gradual development of coma and death. 

Creolin is a carbolic preparation making with water a 
mixture resembling chocolate and milk in color. It is 
slightly oily, has a strong and not unpleasant odor, is 
less poisonous than carbohc acid, but in 2 per cent, solu- 
tions is sometimes very irritating. It stains Hnen and 
rubber sheeting badly. Creolin is a very useful antisep- 
tic in many sorts of gynecologic treatment, as it is anti- 
septic and lubricant as well. 



VAGINAL DOUCHES, 285 

Lysol is a refined preparation of creolin, which has all 
of its advantages without some of its unpleasant features. 
Lysol is much the color of brandy, is slightly oily, and 
has a clean and pleasant odor. It is employed in i per 
cent, solutions for douching, and is often used for wash- 
ing out the uterus after curetting. Like creolin, it 
usually mixes well with water, and accidents seldom 
occur in its use. It is more expensive than creolin or 
carbolic acid. Cresol much resembles lysol and is pre- 
ferred by some. 

Boric-acid douches are unirritating as a rule, and may 
safely be entrusted to a patient. A tablespoonful of 
borax to a quart of water is not too strong, and a table- 
spoonful of boric acid to two quarts is frequently used. 
If it does not readily dissolve, the addition of a tea- 
spoonful of glycerin to the quart will assist in its solution. 
Boroglycerid is a combination of boric acid and glycerin 
frequently used in gynecologic practice. It is employed 
upon tampons and in douches. It may be used as boric 
acid would be. 

Thymol is an oily substance derived from thyme, and 
has been used in i per cent, solution as a mild antiseptic. 

Potassium Pe^nnaiiganate . — In cases of cancer potas- 
sium permanganate is often used in vaginal douches. 
The strength must be prescribed by the physician. The 
color of the solution is usually that of port wine. It is 
unirritating, and very useful in destroying the foul odor 
which arises from cancer. 

Salt Sohition. — This solution is often employed in 
washing out the uterus after curetting, or in douching the 
vagina after some of the major operations. It may be 
prepared by adding one and a half drams of table-salt to 
two pints of water. This solution must then be sterilized 



286 DOUCHES. 

by boiling for thirty minutes. It is usually given at a 
temperature of from 85° to 95° F. 
The Temperature and Quantity of Douches.— 

Hot douches are given at a temperature of from 110° to 
120° F. Warm douches are from 100 to 110° F. 
Douches for cleansing or antisepsis are from 85° to 
90° F. To accom.plish much, at least two quarts of fluid 
are required for a douche, and one gallon should be 
employed whenever possible. 

Syringes and Douche-tubes. — The fountain- 
syringe is the only one to be chosen for this purpose. 
The Davidson syringe is liable not to work properly by 
reason of its valves, and may become so soiled that it 
cannot be cleaned. Piston-syringes are not always easy 
to manipulate, and may force the fluid with too great 
violence. A fountain-syringe should be of good quality, 
containing two quarts, and have a large and good rubber 
tubing connected with it. The catch upon the tubing 
should be one which can be completely opened or closed, 
and not one which exercises considerable pressure upon 
the tube constantly. 

The best douche-tubes are of glass, and should be 
made of especially chosen glass that the danger of break- 
ing may be reduced to a minimum. The writer employs 
a douche-tube made for him, which can be used in 
obstetric practice to wash out the uterus should hemor- 
rhage occur after labor. It is made of especially selected 
glass, and has along the under surface a groove which 
provides a return flow for the fluid used. Such a tube 
can be boiled with other instruments and thus made 
thoroughly sterile. When not in use it should be kept 
in a solution of soda or in a solution of carbolic acid or 
lysol. Hard-rubber tubes are next to glass in value, but 



VAGINAL DOUCHES. 2% J 

cannot be thoroughly boiled without softening. Com- 
plicated metal tubes for douching the uterus or vagina 
are exceedingly hard to clean and sterihze, and are seldom 
used. They must be taken apart to be cleaned, and the 
joints and thread are especially likely to retain mucus, 
blood, or pus. In hospital practice a douche-tube used 
for one patient should not be employed for another while 
the first patient is under treatment. The tubes should 
be placed in jars, filled with antiseptic fluid, when not in 
use, and the jar labelled with the name of the patient. 
In this manner the danger of contagion is reduced as 
much as possible. 

Posture of Patient. — Patients are usually placed in 
the dorsal position to receive douches. The physician 
may order the pelvis raised, and occasionally the patient 
is turned upon the side or placed in the knee-chest 
posture. 

Douclie-paiis. — In lack of other appliances a douche 
may be given with a tin basin to receive the return fluid. 
If the patient be placed upon a folded quilt, the edge of 
the basin may be passed beneath the buttocks, and thus 
a considerable quantity of fluid may be used in the 
douche without soiling the bed. If the patient be turned 
across the bed and brought to the edge, a piece of rubber 
sheeting or oil-cloth may be placed beneath her, brought 
into a bucket under the bed, and the douche given with 
this precaution. A firmly rolled sheet or large towel 
should be placed beneath the rubber sheet under the 
patient's back, to prevent the fluid from getting into the 
bed. It is best, however, in giving douches to use a douche- 
pan, bed-pan, or some other appropriate contrivance (Fig. 
78). Douche-pans are of various kinds. Some are 
made of tin, having an exhaust-tube at the side which 



288 DOUCHES. 

allows the water to run out as fast as the douche is used. 
Others are of agateware and still others of rubber or of 
earthenware. It is usually a comfort to the patient if 
that portion of the douche-pan upon which the body- 
rests be covered by a towel. If a bed-pan is employed, 
a folded towel should be placed beneath the patient's 




douche-pan. 



back where it rests upon the pan. In some cases covers 
are made for a bed-pan which can be slipped on and 
removed and washed after use. The Kelly pad is espe- 
cially useful in the giving of douches. This should be 
well inflated, and care taken that the pad is placed upon 
some firm substance in the bed. If the bed is soft and 
sinks under the patient, no douche-pan will prevent the 
spilling of fluid. If the bed be firm, or if the pad or 
douche-pan be placed upon a firmly folded sheet or 
other material, the douche can be neatly given. Douche- 
pans must be kept absolutely clean, being washed with 
soap and hot water or hot soda solution after each using 
and carefully dried. They should not be kept in the 
patient's room under any circumstances, and should not 
be placed in a closed cupboard or closet. They should 
be allowed to dry thoroughly in the air. The Kelly pad 
should be allowed to collapse after it is used, and should 
be thoroughly washed and dried. It may then be hung 
up to become perfectly dry. 

Method of Giving Douches. — Probably no treat- 
ment can be so successfully carried out and with such 



VAGINAL DOUCHES. 289 

little discomfort if the nurse has tact and skill, or may 
become a source of annoyance and in some cases of 
positive injury. The necessity for absolute cleanliness 
with ever>'thing connected with the patient and the 
appliances used cannot be too strongly emphasized. 
The nurse should receive from the physician definite 
instructions as to the number of douches, the composi- 
tion and quantity of each, and the time for administration. 
The posture of the patient must also be described. The 
bladder should be emptied before the administration of 
the douche, and the fluid should be prepared in accord- 
ance with the doctor's orders. If the weather be cold, 
the nurse must see that the douche-pan or apparatus is 
warmed. The nurse should prepare the fluid, testing its 
temperature with a thermometer. There should be in a 
sterile pitcher an additional supply of fluid. Having 
placed the patient comfortably upon the douche-pan, her 
limbs protected by sheets or folded blankets, the nurse 
should scrub her hands with soap and water, then rinse 
them thoroughly in hot water, and then scrub them in 
mercuric chlorid solution (i : 2000). She should then 
cleanse the external parts of the patient with sterile cotton 
and an antiseptic solution. Usually mercuric chlorid 
(i : 2000) is employed. The douche-tube should have 
been boiled, and brought to the bedside in a basin or 
sterilizer with sterile water. Taking two bits of antiseptic 
cotton or gauze and handling the douche-tube and the 
rubber tube with them, the nurse may connect the two, 
the douche-bag having been hung not higher than four 
feet above the patient at a convenient distance. The 
nurse should be careful not to touch that portion of the 
douche-tube which is inserted within the body. With 
the thumb and fingers of the left hand she should then 

19 



290 DOUCHES. 

separate the labia, introducing the tube gently with the 
right hand. Just before the introduction of the tube the 
fluid should be allowed to run through the rubber tubing. 
The douche-tube should then be passed gently down- 
ward and backward until three or four inches of it are 
within the patient's body. The nurse must see that the 
fluid in the bag does not become entirely exhausted, as 
air would be injected and injury might result. Just 
before the whole amount of fluid has been exhausted the 
nurse should carefully withdraw the tube, placing it in a 
basin of bichlorid solution and cotton. She should then 
dry the external parts with sterile cotton, and dry the 
back or any other portion of the body which may have 
become wet. If douches are carefully given, they are a 
source of benefit and comfort in properly selected cases. 
Cautions and Dangers in the Use of Douches. 
—A nurse should not accept the responsibiHty of giving 
intra-uterine douches. Such should be administered by 
the physician himself During the giving of the vaginal 
douche the patient may complain of severe pain in the 
lower part of the abdomen, with a sensation of faintness 
and nausea. This usually arises from the entrance of 
some of the fluid into the uterus, producing irritation 
and setting up sudden and painful uterine contractions. 
Such uterine colic, as it is termed, while not dangerous, 
is excessively distressing to the patient and even alarm- 
ing. This accident is best avoided by not introducing 
the douche-tube too far, by not hanging the douche-bag 
too high above the patient's head, and by gentleness in 
the administration of the douche. Sometimes air and 
not fluid is injected into the uterus in the giving of 
douches. If considerable violence be employed, air may 
enter the veins and sudden death may result. This has 



VAGINAL DOUCHES. 29 1 

been observed in cases in which fluid was injected very 
forcibly into the womb, usually for criminal purposes. 
A nurse may infect a patient, especially after labor or an 
operation, by unclean douche-tubes, by fluid not prop- 
erly sterilized, and by dirty hands and appliances. She 
may also do damage if she introduces a douche-tube 
forcibly and thrusts it too far into the body of the patient. 
If the solution be too strong or if the medicine employed 
be not properly dissolved, fatal poisoning and burning 
may result. A case came under the writer's observation 
during the time when carbolic-acid douches were exten- 
sively employed, in which a night-nurse was given a 
solution of carbolic acid not perfectly dissolved. From 
this solution, five patients received douches at various 
stages of the lying-in period. Of these, three died as the 
result of burns received from the douche fluid. 

Douches after Plastic Operations. — After opera- 
tions upon the cervix, vagina, pelvic floor, and perineum 
douches are often employed to cleanse the stitches and 
promote healing. The composition of the douche will 
be ordered by the physician. They are usually dilute 
antiseptic solutions. In inserting the douche-tube in 
such a case the nurse should know in what part of the 
vagina the stitches have been placed. If upon the pos- 
terior wall, she may carry the tube gently but firmly along 
the anterior wall. If, on the contrary, the stitches have 
been placed in the anterior vaginal wall, the tube should 
be pushed gently backward, thus avoiding the stitches. 
The douche-tube is one of the best means for cleansing 
stitches, and may be inserted but a part of the way, just 
sufficiently to carry the fluid to the stitches. Better than 
the use of the tube in skilful hands is the method of 
cleansing stitches by pouring antiseptic fluid from a small 



292 DOUCHES. 

pitcher. If the labia be separated by the thumb and 
fingers of the left hand, fluid may be so poured upon the 
parts as to cleanse them very efficiently. 

INTESTINAL DOUCHES. 

In many invalid women chronic disease of the intes- 
tines is one of the chief complications of the case. Such 
require especial treatment, and intestinal douching may 
be employed. 

Solutions. — Normal salt solution and solutions of 
sodium bicarbonate or sodium salicylate are most fre- 
quently used. The quantity employed is usually from 
one to two gallons. The temperature varies from 90° 
to 70° F. 

Tubes for Intestinal Douching. — The best tubes 
for this purpose are of the best quality of rubber, usually 
red in color and of medium size. The nurse will find 
that the medium-sized tubing is better than the small. 
It is a waste of money and effort to procure any but the 
best tubing, as the cheaper soon loses its elasticity and 
is very unsatisfactory. A fountain-syringe is employed 
to hold the fluid, and as the quantity used is consider- 
ably larger than in vaginal douching several pitchers are 
employed for this purpose. 

Posture of the Patient. — In most cases the patient 
is turned upon the left side and the pelvis slightly raised. 
Occasionally the knee-chest posture is employed during 
a part of the douching. 

Method of Giving. — If a large intestine is to be 
douched, the rectum must be first emptied. Accord- 
ingly the bowels must have been moved by medicine or 
by an enema before the douche is given. Having pre- 
pared the fluid, and having sterilized the tube in an anti- 
septic solution and the patient being in position, the tube 



VESICAL DOUCHES. 293 

is attached to the fountain-syringe and is lubricated with 
sterile olive oil, glycerin, or an ointment prescribed by 
the physician. Allowing the fluid to run, the nurse 
introduces the tube, gently giving it a slightly spiral 
motion. If the tube meets much resistance, the nurse 
should stop and hold it at the point already inserted. 
With patience and gentleness she can usually succeed 
in introducing the tube a very considerable distance. It 
may be inserted as far as it will go without injury if gen- 
tleness be used. The fluid should be allowed to run 
freely, and the patient urged not to strain or bear down. 
As the intestine becomes distended the patient will have 
a desire to empty the bowel, but this should be resisted 
until the bowel is as full as possible. The patient may 
then allow the fluid to escape, or, if the physician ad- 
vises, she may rise and use a commode. If it is desired 
to have the fluid return promptly, a large-sized soft cath- 
eter may be inserted along with the douche-tube, provid- 
ing for a return flow of the fluid. In some cases the 
nurse practises gentle massage of the abdomen with the 
left hand while inserting the tube with the right. The 
patient may be placed in the knee-chest posture in some 
cases, as the fluid will then gravitate into the transverse 
colon, completely distending the bowel. 

VESICAL DOUCHES. 

In cases of inflammation and catarrh of the bladder 
vesical douches are a very efiicient means of treatment. 
In many cases their administration is carried out by the 
physician, as he may desire especially to judge of the 
results of the treatment. In other cases this method is 
entrusted to a nurse. 

Fluid Employed.— A saturated solution of boric 
acid, sterile water, nofmal salt solution, lysol or creolin 



294 DOUCHES. 

(i per cent.) are the fluids most often used. At first a 
small quantity only is introduced within the bladder, but 
as the patient grows accustomed to the treatment from a 
pint to a quart may be used. In some cases several 
quarts are employed. The temperature of the solution 
should be from 85° to 90° F. In some cases it may be 
from 90° to 100° F. 




Fig. 79.— Apparatus for washing the bladder (Penrose), 

Posture and Preparation of the Patient. — The 

patient lies in the dorsal position, and need not be 
brought to the edge of the bed or table. The douche 
can usually be given while the patient lies in bed in the 



VESICAL DOUCHES. 295 

ordinary posture. In some cases the pelvis may be 
raised. The patient should be prepared by having the 
external parts thoroughly cleansed with soap and water 
and rinsed with water, and then with mercuric chlorid 
(i : 2000). The apparatus required should be thoroughly 
cleansed and the catheter sterilized by boiling. The 
solution must be prepared and readily available, and a 
basin should be placed between the patient's thighs. If 
she be put across the bed, a Kelly pad may be used and 
a slop-jar as for a vaginal douche. As it is often desirable 
to save a specimen of urine for examination, a clean six- 
ounce bottle and cork should be in readiness. 

The apparatus required consists of a medium-sized 
soft-rubber catheter, a piece of glass tubing several inches 
long, a piece of good quality rubber tubing two feet 
long, and a medium-sized glass funnel (Fig. 79). The 
funnel and rubber tubing and glass tubing should be 
connected first. 

Method of Giving the Douche. — After the nurse 
has cleansed her hands and made them antiseptic, the 
catheter, having been previously boiled, should be lubri- 
cated with sterile olive oil or sterile glycerin. It should 
then be introduced and the urine allowed to escape. If 
desired, it should be reserved for examination. The 
catheter should then be withdrawn and connected with 
the glass tubing. The funnel should be held about three 
feet above the patient and be filled with the solution 
desired, which is allowed to begin to run through the 
catheter. The catheter should then be introduced again, 
and the fluid should continue to run until the bladder 
begins to be distended. The patient will usually com- 
plain of slight pain or sense of distention in the bladder. 
When the fluid has ceased to run easily from the funnel 



296 DOUCHES. 

the funnel should be filled and quickly depressed below 
the level of the patient. The fluid in the bladder will 
then escape by siphon action. This must be done as 
gently as possible, the character of the fluid returning 
being closely watched. The washing must be repeated 
until the fluid returns perfectly clear. To remove the 
catheter, it should be disconnected from the glass tubing 
and the finger be placed over the end of the catheter. 
It may thus be withdrawn without soiling the parts with 
discharges from the bladder. After the douching the 
parts about the meatus should be thoroughly cleansed 
with sterile water and sterile cotton. As many cases of 
disease of the bladder suffer great pain and the bladder 
becomes exquisitely sensitive, the nurse must be very 
gentle in her manipulation. In severe cases the bladder 
will not retain more than an ounce or two of fluid, and 
yet the washing of the bladder with this small quantity 
of warm, sterile fluid often gives considerable relief 

Care of the Apparatus [Employed.— It is of the 
greatest importance that catheters be kept absolutely 
clean. They should be boiled for from twenty to thirty 
minutes in soda solution and kept in a solution of lysol 
or carbolic acid. Before using the catheter must be 
thoroughly flushed out with hot or sterile water. Unless 
the greatest caution be observed in the care of catheters, 
it is possible that the treatment may indefinitely prolong 
and even aggravate the disease. 



CHAPTER V. 

GENERAL CARE OF GYNECOLOGIC PATIENTS. 

REST. 

In many cases the patient's suffering has been greatly 
aggravated by her efforts to perform duties for which 
she is physically incapable. In her weakened condition 
each pain has been aggravated, and it is impossible to 
estimate accurately her symptoms or give her prompt 
relief without putting her at rest. In some cases rest in 
bed during the entire day is impossible and even unde- 
sirable, but in these cases a number of hours of rest in 
bed will be definitely prescribed. Rest also implies not 
only the recumbent posture, but also freedom from an- 
noyance and interruption. It is very hard for the mother 
of a family to obtain this or for those who have others 
dependent upon them. In aggravated cases the patient 
is far better in a hospital, where a rest-cure may be added 
to other methods of treatment. In the matter of rest, it 
is the nurse's duty to obtain from the physician definite 
orders as to the number of hours of rest desired, and 
whether that be absolute or partial. These orders the 
nurse must carry out accurately but kindly. When 
complete isolation is required no one should see the 
patient but the nurse and the physician. The patient 
must abandon for the time communication with the ex- 
ternal world, not receiving mail or communications of 
any sort. While the first few days of such a procedure 

297 



298 GENERAL CARE OF GYN&COLOGIC PATIENTS. 

may be irksome and trying for the patient, the good 
effect is very soon manifest. 

FOOD. 

These patients are almost invariably badly nourished, 
and require persistent and very careful feeding. Many 
of them positively assert that they cannot take milk, and 
others have appetites so degenerated that they prefer 
only indigestible and poorly nourishing food. Food 
must be prescribed for these patients as definitely as 
medicine would be. The nurse must keep a faithful 
record of the amount and sort taken, with the intervals 
of feeding. Food must be administered regularly, and 
usually without questioning the appetite of the patient. 
As her strength increases and she becomes rested a 
healthful appetite will return. Much can be done if the 
nurse will make the food as palatable as possible, and 
will serve it in an agreeable and absolutely neat manner. 

Forced Feeding in the Insane. — With insane 
patients who will not take food, artificial feeding must be 
practised, sometimes for months or even years. The 
best method consists in feeding by the nose through a 
tube passed through the nostrils into the esophagus. As 
the patient can take liquids only by this method, she 
must be fed every three or four hours. If milk is em- 
ployed, it must often be predigested. Some of these pa- 
tients will drink water, while others refuse both food and 
drink. In caring for these cases a nurse must have pre- 
cise written directions as to what sort of food shall be 
given ; the quantity, temperature of the food, and inter- 
vals of feeding. Tubes used for this purpose must be re- 
peatedly sterilized by boiling, and when not in use kept 
in a saturated solution of boracic acid. Maniacal patients 



FOOD — WATER. 299 

may require restraint, either constantly or during feeding. 
Even in these cases it is sometimes difficult to use the 
tube. With patience and tact, however, the result can 
usually be pbtained. Medicines are often added to food, 
which disguises them for patients who will not swallow. 
Rectal Feeding. — In some cases forced feeding 
through the nose may be supplemented, or substituted 
by rectal feeding. P'or this purpose solutions and mix- 
tures already prescribed in treating the pernicious nausea 
of pregnancy may be employed. The rectum should 
be thoroughly irrigated once in twenty-four hours with 
warm salt solution. Rectal tubes should be repeatedly 
steriHzed by boiling, and when not in use kept in boracic 
solution, creolin, or lysol. In giving these injections the 
patient should be turned upon the left side with the pel- 
vis raised, and a pad should be placed over the bowel so 
soon as the injection is given. Medicines are frequently 
added to rectal injections. 

WATER. 

In such patients the excretory organs perform their 
duties imperfectly, and it is desirable that the patient 
take a large quantity of water. This must be given at 
regular intervals, and its importance must not be over- 
looked. The physician should prescribe what sort of 
water the patient is to have. Saline waters abound, and 
are very useful in the treatment of these cases. So 
simple a thing as water may be given in a very desirable 
manner. If the water is not cool and refreshing, if the 
glass in which it is given is not clean, if empty water- 
bottles are allowed to accumulate in the room, the patient 
may be so disgusted that she will fail to take the required 
amount. Very few persons take sufficient water, and so 



300 GENERAL CARE OF GYNECOLOGIC PATIENTS. 

the formation of this new habit may be a novelty to the 
patient and one resulting in great good. 

THE EYES. 

Many of these patients have poor sight, and the eyes 
require the aid of glasses. Others have catarrhal inflam- 
mation of the eyes of a chronic nature. Some cannot 
read while lying in bed, and hence the nurse must read 
to them. The nurse should take care that they do not 
fatigue the eyes by improper and prolonged use. 

THE CARE OF THE SKIN. 

Such patients excrete badly through the skin and 
require constant attention. A soap-and-water sponge- 
bath in the morning, and an alcohol sponge with light 
massage at night, form a useful treatment in most cases. 
The physician may prescribe medicated baths, to be given 
by sponging, packing, or in the tub. Such are effervescing 
saline baths, bran baths, salt baths, or sitz -baths. In tub- 
bathing the nurse must be careful that the bath is of the 
proper temperature, and that the patient does not remain 
in the bath too long. For neurasthenic patients a spray- 
and-needle bath is sometimes employed with good re- 
sults. The wet pack to relieve insomnia or the pack to 
reduce fever may also be employed. The administration 
of baths is a good test, for the nurse's skill and tact are 
no more manifest than in this treatment. The avoidance 
of scented soaps and absolute cleanliness in sponges or 
wash-cloths are demanded. Many prefer not to use sea- 
sponges, as it is practically impossible to clean them, but 
use knitted wash-cloths, which can be repeatedly boiled. 

Manicuring and Pedicuring. — The hands and feet 
of patients should receive daily attention. The arts of 



CARE OF THE MOUTH AND TEETH. 3OI 

the manicure are required, and will be greatly appreciated 
by these cases. Many patients do not feel clean and 
comfortable unless this matter receives attention. 

CARE OF THE MOUTH AND TEETH. 

Nurses should see to it that these patients receive con- 
stant care of the mouth and teeth. Very frequently, dis- 
ordered secretions in the mouth give a constant bad 
taste and annoy the patient greatly. The mouth should 
be rinsed frequently with a mild antiseptic, such as 
boracic-acid solution, or some solution containing thymol. 
The teeth should be brushed frequently, and if the gums 
are soft and spongy, applications of myrrh and other 
astringents should be made. 

Massage is a most useful adjunct in the treatment 
of these cases. Such may be general massage, intestinal 
massage, or pelvic massage. 

General Massage. — In general massage the available 
muscles of the entire body are picked out by the masseuse 
and subjected to kneading, rubbing, or tapping. As 
most women with pelvic disease are malformed through 
improper clothing, the muscles of the back will be found 
very deficient in development. Massage is especially 
useful with these patients in bringing them into proper 
development. Other women are abnormally fat, and the 
waist must be reduced by vigorous rubbing and knead- 
ing. In connection with general massage, oil inunctions 
are sometimes practised in cases of profound anemia. 

Intestinal Massage. — When constipation is obstinate 
intestinal massage may be given daily, and is sometimes 
combined with douching of the intestine. The rubbing 
should follow the course of the large intestine, beginning 
upon the right side near the groin, passing up along the 



302 GENERAL CARE OF GYNECOLOGIC PATIENTS. 

right, across the center, and down the left side. The 
rubbing should be gentle but thorough. 

Intestinal Massage zvitJi Salijics. — In cases where the 
patient is greatly annoyed by gas and other forms of in- 
digestion, she will be greatly benefited by drinking hot 
water, and then receiving massage beginning over the 
stomach and extending along the intestine. In many 
cases Carlsbad salt, sulphate of magnesia, or Rochelle 
salt may be added to the water which is taken, greatly 
to the patient's advantage. 

Pelvic Massage, — This special branch of massage is 
designed for the treatment of some obstinate cases of 
pelvic inflammation. A nurse should not attempt it 
without personal instruction from a physician or one 
skilled in its use. To perform this treatment, a vaginal 
douche of an antiseptic solution is first given. The 
patient is in the dorsal position, with her limbs flexed and 
her feet resting on chairs. The head and shoulders are 
raised. Having made her hands aseptic, the nurse 
anoints the fingers of one hand with an antiseptic oint- 
ment and inserts them within the vagina. The other 
hand is placed upon the abdomen of the patient behind 
the pubes. When the position of the womb has been 
outlined by the internal hand gentle rubbing and pressure 
are made upon the tissues which are felt to be in a resist- 
ing and unelastic condition. As the fingers are passed 
deeply downward and backward the effort is made very 
gently to raise the w^omb upward and forward. Should 
the patient complain of severe pain the effort should stop 
at once. It is evident that this form of massage if im- 
properly done might result in very serious injury. 
Those nurses who desire to make obstetric and gyne- 
cologic work a specialty may take the opportunity to 



ELECTRICAL TREATMENT. 303 

receive instrtiction in this branch of massage, as they 
will sometimes find occasion to practise it. 

Postural Gymnastics. — In connection with pelvic mas- 
sage, patients may be taught to assume postures and to 
make voluntaiy movements which will strengthen the 
muscles of the pelvic floor and thus strengthen the sup- 
ports of the womb. In some cases the patient is placed 
upon the back, and the nurse, taking the thigh and 
flexing it, causes the patient to resist or to push down- 
ward with the thigh and leg. This resistance puts into 
action certain muscles of the pelvis which are weak. In 
other cases exercises of a similar nature are employed. 
In connection with such gymnastics Swedish movements 
may be given to the patient, with or without machines 
adapted to the purpose. Pelvic massage and postural 
gymnastics are a special branch of massage and physical 
training which must be learned from those especially 
fitted to teach and practise it. 

ELECTRICAL TREATMENT. 

Electricity is often employed to strengthen the nervous 
systems of invalid women. The administration of the 
current may be assigned to the nurse. Both the faradic 
and the galvanic current are used as directed by the 
physician. In some cases the faradic current is employed 
to contract the muscles ; in other cases the faradic cur- 
rent is employed as a general stimulant ; while in still 
others the galvanic current is used in the treatment of 
pelvic neuralgia. The nurse must receive from the phy- 
sician definite instructions regarding the use of electricity, 
the length of time that each current is to be employed, 
and the method of its administration. She must be 
careful in the care of the battery that the carbons are 



304 GENERAL CARE OF GYNECOLOGIC PATIENTS. 

removed from the fluid when not in use, and that battery 
fluid is not spilled upon the metal portions of the battery. 
She must also take pains that the electrodes are kept 
clean, that clean cotton is employed to cover them, and 
that the water with which they are moistened is of a 
comfortable temperature. Care must be taken that the 
patient does not become chilled during the use of elec- 
tricity, and that the administration is not too prolonged. 
A record should be kept of this treatment, as of all other 
treatment adopted in any case. 

THE CARE OF THE INTESTINES. 

It is of paramount importance that all patients have 
proper evacuation of the intestines. To bring this about 
the nurse may employ under the doctor's orders supposi- 
tories, enemas, or lavage. The diet may be so regulated 
as to favor the avoidance of constipation, and the precise 
method of relieving the difficulty will be decided by the 
physician. It is the nurse's duty, however, to note any 
tendency to constipation, and to report it at once to the 
physician for his treatment. 



CHAPTER VI. 
GYNECOLOGIC OPERATIONS. 

These may be conducted in hospitals or in private 
houses. No two operators perform the same operations 
in precisely the same way, and in no tw^o operators' 
operating-rooms are precisely the same regulations en- 
forced. It is the duty of the nurse to learn thoroughly 
the methods of the operator with whom she is working. 
If she assists him for the first time, she should if possible 
obtain from him definite directions regarding the arrange- 
ment of the details of the operation and make written 
notes of his wishes in this matter. It is unsafe to trust 
to a verbal understanding of such important things. In 
hospital operating-rooms the great advantage of suitable 
appliances is very evident, w^hile in private houses the 
ingenuity of the nurse and operator is often severely 
taxed to supply the deficiency. 

Gynecologic operations from the standpoint of gravity 
may be divided into those in which the peritoneal cavity 
is not opened and those in which the peritoneal cavity is 
opened. Infection of the peritoneum is so dangerous 
that the division may be based upon the presence or 
absence of an opening into this important portion of the 
body. 

OPERATIONS IN WHICH THE PERITONEAL CAVITY 
IS NOT OPENED. 

Such are dilatation and curetting of the womb, the 
removal of small tumors from the womb, operations upon 

20 305 



306 GYNECOLOGIC OPERATIONS. 

the womb to straighten or enlarge its cavity, operations 
to remedy deformities in the vagina, operations for 
tumors of the vagina and labia, and operations upon the 
urethra or the neck of the bladder, and those performed 
upon the rectum. The removal of cancer from the neck 
of the womb is also included in this division. Plastic 
operations performed to remedy lacerations occurring at 
labor come under the head of obstetric surgery. 

Preparation of Patient. — For all these operations 
the bowels must be thoroughly emptied. A specimen 
of urine must be sent to the physician for examination, 
the action of the skin must be stimulated by baths, and 
the patient should be prepared by several days' rest in 
bed and by very nutritious but easily absorbed and 
digested diet. 

Disinfection of the Field of Operation. — The field of 
operation must be disinfected by the repeated application 
of cleansing and antiseptic substances. Scrubbing the 
mucous membrane of the vagina with tincture of green 
soap or green soapsuds, by cotton pledgets and dressing- 
forceps, followed by copious douching with sterile water 
and bichlorid solution, is the method usually employed 
for preparing this portion of the body. The physician 
may trust to vaginal disinfection to prepare the cervix for 
operation, or he may cleanse it himself by suitable appli- 
cations. If the neck of the bladder or urethra is to be 
operated upon, it may be necessary to douche the blad- 
der for several days after the manner described in the 
chapter on Douches. The physician may make applica- 
tions to the urethra for several days before operating, to 
bring about a healthy condition of the mucous membrane. 
Disinfection of the bowel is accomplished by douching 
and by very copious irrigation with warm salt solution. 



EXTRAPERITONEAL OPERATIONS. 307 

As many of these patients suffer from hemorrhoids, care 
must be taken not to wound these structures. Lysol is 
preferred by many in the disinfection of the rectum and 
adjacent tissues. The hair should be carefully trimmed 
from the parts, or the parts may be shaved if the operator 
so desires. 

Dress of the Patient. — For such operations, unless the 
weather be excessively hot, the patient should wear a 
Hght woollen undershirt and a short night-dress or bed- 
gown. The lower limbs should be covered with canton- 
flannel leggings reaching to just below the groin. The 
shirt may be omitted if the heat be excessive. 

P^'eparation for Anesthetic. — For anesthesia, the stom- 
ach should be empty, false teeth should be removed, the 
hair should be braided, the lips and nostrils lightly 
smeared with cold cream or vaseHn, and the clothing 
about the neck and throat perfectly loose. 

Preparation of Room in Private House. — Many 
of these operations are performed in private houses, and 
due attention must be given to the preparation of the 
room. As clean and hght a room as possible should be 
selected. It should be upon the same floor with the 
bath-room and closet, but preferably without plumbing 
connecting with the sewer. If a bed is employed, it 
should be narrow and high, with a firm, smooth mattress. 
It will add much to the comfort of the operator and nurse 
if a table be improvised, using a clean kitchen-table cov- 
ered with blankets, a rubber sheet, and sheet. Unneces- 
sary furniture should be taken out of the room if it be 
small. A number of basins and pitchers must be thor- 
oughly scrubbed and rinsed with boiling water. The 
table should be so arranged that the best available light 
will fall upon the seat of operation. The nurse should 



308 GYNECOLOGIC OPERATIONS. 

secure some means of holding the irrigator or douche- 
tube. A portable clothes-stand is very convenient for this 
purpose. A Kelly pad should be placed upon the table, 
and beneath it a slop-jar or a large pan to hold fluid. 
The lower half of the windows, if there is a possibility of 
observation, should be occluded by paper or other im- 
pervious material. 

Steriliser and Instruments. — Physicians often 
have their instruments and dressings steriHzed in a hos- 
pital in a portable sterilizer. This can be taken to the 
house of the patient and not opened until the time of 
operation. Other physicians bring their instruments in 
sterilizing trays, boiling them just before the operation. 
If neither of these devices is used, the nurse may be 
required to boil the instruments in the cleanest available 
pan or basin. Brown soap and soda with plenty of boil- 
ing water will clean a basin sufficient to make it prac- 
tically safe. A teaspoonful of soda to a quart of water 
should be used to boil instruments, to prevent rust and 
injury to the instruments. If the physician is to use the 
cautery, the nurse may be expected to assist in its man- 
agement. She should be informed of this and told ex- 
actly w^hat she is to do before the operation commences. 

Needles and Sutures.— These should be sterilized 
and prepared as the physician desires, and it is well to 
separate them from the other instruments in a different 
basin or pan. If the nurse is familiar with the operation 
and the operator, she will know regarding the number 
of sutures probably required and their kind. 

Solutions and Stimulants.— Antiseptic solutions 
as ordered must be in readiness, with a plentiful supply 
of hot water. The nurse must take especial care that 
antiseptic solutions are not left in a private house. Chil- 



EXTRAPERITONEAL OPERATIONS. 309 

dren or servants may mistake them for water or for some 
harmless substance, and cases of poisoning have arisen 
from this source. This is especially true of white tablets 
of mercuric chlorid, which a child might mistake for 
candy. The nurse remaining in charge of the patient 
can take care of antiseptics while she is with the patient, 
and when she goes any remaining should be destroyed 
or given in the care of the mother with suitable caution. 
The nurse will be expected to see that whiskey or brandy 
is available during the operation. Private patients some- 
times offer wine as a substitute, but this should not be 
accepted. 

The nurse should see to it that a plentiful supply of 
clean linen and such surgical dressings as the physician 
requires are on hand. With good care a nurse can save 
the patient's linen while still keeping her perfectly clean. 
Old sheets if thoroughly clean should be used for opera- 
tions, and often by tearing a large sheet in halves these 
can be used for wrapping the patient's Hmbs much more 
conveniently than the larger sheet. As linen used for 
an operation may be stained by antiseptics, the best linen 
should not be selected for this purpose. Sterile or anti- 
septic vulvar dressings and sterile or antiseptic gauze 
pads will be required. Strips of sterile gauze for packing 
should also be in readiness. The physician sometimes 
brings gauze in sealed glass jars, and in other cases relies 
upon gauze sterilized and wrapped in sterile towels. 
While sterilizing the instruments the nurse should boil 
a half dozen towels, which may be wrung out and kept 
for handling sterile gauze. 

Operations of this Sort in Hospitals.— These 
operations are usually performed in the general operating- 
room or the minor surgical operating-room of hospitals. 



310 GYNECOLOGIC OPERATIONS. 

As the portions of the body operated upon are rarely in 
a perfectly aseptic condition, it is better to perform such 
operations in a different room from that in which ab- 
dominal surgery is practised. 

The After-care of these Patients.— From two 
weeks' to one month's rest in bed is required after these 
operations. During the greater part of this time the 
nurse must apply surgical dressings to the vulva or anal 
region, retaining them in place by a T-bandage. The 
use of a catheter is often necessary with these patients. 
The bowels must be moved by enemas, and very fre- 
quently lavage of the intestines must be practised in 
addition. Vaginal douches are often required during 
convalescence. The diet as ordered by the physician 
must be nourishing and easily digestible, and the general 
care of the patient must be that given to all surgical 
cases. Surgeons often utilize the opportunity while the 
patient is in bed to build up the general health of the pa- 
tient in every possible manner. Selected feeding, mas- 
sage, electrical treatment, tonic drugs, are all employed 
to bring about the best general result. The nurse who 
cares for these patients must add to her surgical knowl- 
edge the thorough understanding of the best medical 
nursing. 



CHAPTER VII. 

OPERATIONS IN WHICH THE PERITONEAL 
CAVITY IS OPENED, 

The peritoneal cavity is opened through the abdomen 
by the performance of celiotomy, or abdominal section. 
It may also be opened through the vagina by an opera- 
tion often termed vaginal celiotomy. 

NATURE'S SAFEGUARDS. 

In order to understand the care of the patient for one 
of these operations, the nurse should know something 
of the way in which Nature protects patients against the 
dangers to which they are exposed. The peritoneum, a 
delicate membrane of large extent, is easily wounded or 
infected and yet recovers very quickly under favorable 
conditions. The cells of this membrane and the blood- 
cells circulating through it are capable of absorbing a 
considerable quantity of foreign and poisonous matter, 
and destroying it. Wounded surfaces in the peritoneum 
heal very quickly. In order for these safeguards to be 
most efficient, the patient must have a naturally sound 
and healthy blood, and sound blood-vessels, while the 
lymphatic channels in the peritoneum and bowels must 
be comparatively empty. The kidneys must also be 
healthy, to perform their usual duty. 

To bring about this condition we strive to have patients 
in as good general health as possible before the perito- 

311 



312 INTRAPERITONEAL OPERATIONS. 

neum is opened, while we empty the lymphatic channels 
'by actively purging the intestine. We further contract 
the intestine to its smallest bulk, so that it shall not 
impede the operation, and so that it shall be in as little 
danger of injury during the operation as possible. The 
kidneys are prepared by copiously flushing them through 
the water which the patient drinks, while the skin 
receives attention by baths and massage. 

PREPARATORY TREATMENT. 

Preparatory treatment is often necessarily prolonged. 
If a patient has had a disease for a number of years 
which has been interfering constantly with a healthy 
condition of the abdominal organs, this state of disease 
cannot be remedied at once. In emergency cases the 
patient loses the great benefit of preparatory treatment, 
and the operator must take the chances in view of the 
greater danger which renders the emergency operation 
imperative. 

THE DANGERS OF CELIOTOMY, ABDOMINAL OR 
VAGINAL. 

The great dangers of these operations are from hemor- 
rhage and septic infection. Both through modern science 
are largely preventable, and in the prevention and detec- 
tion of each the nurse has an important duty and re- 
sponsibility. As she often prepares ligatures to control 
hemorrhage, she should detect a weakened ligature and 
report the fact to the physician. As the aseptic prepa- 
ration of the patient is largely committed to her, if she 
is not faithful in her work the patient may become in- 
fected. The same responsibility attaches to the prepara- 
tion of dressings, of pads and gauze sponges, and all 



PRELIMINARY TREATMENT, 313 

articles used about the patient. Instruments or sponges 
left within the abdominal cavity have caused death, and 
this mistake has occurred through an error on the part 
of the nurse in charge of the sponges and instruments. 
In view of these dangers we must remember the impor- 
tance of absolute quiet immediately after such an operation. 
Such reduces the tendency to hemorrhage to the lowest 
point, and favors the healing process going on in the 
peritoneal cavity, and the establishment of those functions 
of absorption and elimination upon which the patient's 
recovery may depend. In many cases the fate of such a 
patient is decided in the first forty-eight hours after the 
operation. We can thus readily understand why it is 
the duty of the nurse to keep the patient absolutely quiet. 

PRELIMINARY TREATMENT. 

Whenever possible, a case requiring opening of the 
peritoneal cavity should come under observation from 
two to four weeks before the operation. The patient 
should be put at rest in bed, and may be allowed to use 
a commode, or, if a bath-room be convenient, to use it. 
Specimens of urine should be sent to the physician for 
examination as often as he may desire. An accurate 
record should be kept of the pulse, temperature, hours 
of sleep, amount of food taken, the number of bowel 
movements, and the amount of urine voided. The diet 
of the patient will be such as to put the digestive tract 
in the best condition for operation. It will usually con- 
sist of nourishing liquid diet in small quantities, at com- 
paratively frequent intervals. 

The Bowels. — The bowels of the patient must be 
very thoroughly emptied by such medicines as the 



314 INTRAPERITONEAL OPERATIONS. 

physician will prescribe, by copious enemas, and by in- 
testinal lavage. In some cases intestinal massage will 
be ordered, while in others it cannot be employed. Un- 
less a nurse has had experience, she cannot appreciate the 
quantity of fecal matter which a patient having a large 
tumor may retain in the intestines. In the writer's 
observation over forty bowel movements in two days, 
with repeated enemas and lavage, were found necessary 
to empty the bowels in such a case. The use of injec- 
tions containing ox-gall or oil or glycerin is often neces- 
sary. In some cases the knee-chest posture must be 
utiHzed to secure the best effect for such injections. The 
effort to empty the intestines may result in the formation 
of large quantities of gas. This is simply an indication 
that the necessity for cleansing the bowel is very great. 
The treatment should continue in such a case until the 
gas has entirely disappeared. When the patient's intes- 
tinal tract is in sound and healthy condition the tongue 
is clean and pink, the abdomen is soft, and the intestines 
are free from gas. 

The Skin. — Attention to the skin is also needed in 
these cases. In many patients it is well to put them 
between blankets instead of between sheets during this 
treatment. A thorough soap-and-Avater sponge-bath once 
daily, and an alcohol-and-water sponge-bath at night, 
are indicated. Excessive sweating or failure to react are 
unfavorable symptoms, and should be reported to the 
physician. 

The Kidneys. — The action of the kidneys will be 
stimulated by the regular and free use of water, and by 
such medicines as the physician may prescribe. The 
amount of urine should be measured and recorded, and 
the record reported to the physician. Any unusual 



PRELIMINARY TREATMENT. 315 

appearance in the urine should also be recorded and 
reported. The urine will be examined. 

The Pulse. — While the nurse is giving the patient 
this preliminary treatment she will have opportunity to 
observe the condition of the pulse and to judge some- 
what of the state of the heart. While it is not her prov- 
ince to examine the heart critically, she should notice a 
tendency to faintness or palpitation of the heart, a very 
small, feeble pulse or a full, hard, and bounding pulse. 
She should notice intermittence of the pulse when she 
takes the temperature and pulse daily. 

Duties and Province of Nurse. — The nurse is 
with the patient more than the physician, and hence has 
greater opportunities for noticing. It is not her business 
to decide or to diagnosticate or recommend treatment, 
but she can never go wrong in noting any symptom, in 
recognizing its importance, and in reporting it promptly. 
An accurate diagnosis in cases of intra-abdominal dis- 
ease is often difficult and sometimes impossible. A con- 
scientious physician may repeatedly examine a patient, 
and will require all the help which the diagnostic art can 
give him to decide accurately the condition. Hence it is 
important that the nurse should be accurate and careful 
in her observations, and faithful and prompt in her 
report. She has also a further province in cooperating 
with the preparatory treatment, and that lies in the men- 
tal condition of the patient. In cases of chronic disease 
the patient through her suffering and disability has been 
finally brought to risk the chance of death to obtain 
relief. Some women are hopeful and calm in this con- 
dition, while others are apprehensive and timid, and 
others profoundly melancholy. They welcome encour- 
agement and sympathy ; and while the nurse should 



3l6 INTRAPERITONEAL OPERATIONS. 

never become sentimental, still her knowledge of medi- 
cine is such and she sees so many successful cases that 
she can greatly encourage the patient in the hope and 
belief that her operation will be successful. A nurse 
should never forget that serious interference with the 
human body is a grave matter. Under no circumstances 
should the nurse become flippant in speaking of an oper- 
ation or its results. A nurse who loves to describe the 
scenes of the operating-room to patients, and to boast 
or joke about them, should not be employed. Such a 
person does infinite harm to her profession and to her- 
self. If a patient is curious regarding the details of the 
operation, the nurse should not satisfy her curiosity. 
Under no circumstances should any remark made by 
the patient while under ether or any untoward happen- 
ing during the operation be repeated. By her quiet, 
courageous, kind, and hopeful demeanor, and by her 
steady and prompt performance of her duties, the nurse 
can play a very important part in the preparation of 
patients for abdominal operations. 

OPERATING=ROOMS. 

In well-equipped hospitals operating-rooms are set 
aside especially for cases requiring abdominal surgery. 
Such rooms are not necessarily large, but they should 
contain those appliances most used in these operations, 
and should be free from the danger of contamination 
which often arises where miscellaneous operations are 
done. If an abdominal section proves to be for septic 
disease, a small room can be readily fumigated and 
should be thoroughly aired afterward. Such a room 
must be so constructed as to be readily made aseptic and 
to stand the wear of frequent cleansing. Its walls, ceil- 



OPERA TING-R O OAIS. 3 1 / 

ing, and floor should be hard and smooth, capable of 
repeated flushing or scrubbing with alkalies and antisep- 
tics. There should be no angular corners or projections 
in the room to favor the accumulation of dirt. The 
room should be ventilated directly to the outside air, or 
into an independent flue which has connection with no 
other flue. It should be heated by the circulation of hot 
water through pipes or by steam, but not from a furnace 
and registers. An open fire with a large flue is especially 
useful. A north light is preferred by many for such a 
room, while gas and the electric light should both be in 
readiness. An accident suddenly shuts off the electric 
light at a most important time, and hence the necessity 
for having two sources for artificial light. No pipe con- 
necting with a sewer should open into an operating-room. 
The effort has been made to drain such rooms by making 
the center lower than the sides, and by the use of a large 
pipe opening in the center of the room. This effort has 
rarely been followed by satisfactory results, as the pipe 
becomes clogged and fluid accumulates in the room. It 
is now considered best not to attempt to drain the floor 
of an operating-room, but to mop up fluid and other 
material which requires removal. 

Anestheti5jing-room.— An operating-room should 
have adjoining to it several small rooms of various sizes ; 
one communicating with the corridor or hall may be 
devoted to anesthetizing patients, so that the patient need 
not witness the preparations for the operation which may 
be going on in the operating-room. Such a room should 
be provided with a suitable bed, unless it is preferred to 
anesthetize the patient on a wheeled stretcher, thus pre- 
venting an unnecessary transfer. The anesthetizing- 
room should be well lighted and heated, and equipped 



3l8 INTRAPERITONEAL OPERATIONS. 

with stimulants, oxygen, and an electric battery. In- 
halers, tongue-forceps, mouth-gag, and tracheotomy set 
may also be kept in this room. 

Sterili^ing-room. — It is also customary to have a 
room for sterilization, adjacent to the operating-room. 
In this may be placed several large steam sterilizers, one 
for instruments, one for dressings, and one for linen. 
These must be connected with steam apparatus or some 
other form of apparatus which supplies steam or heat. It 
is usual to place one nurse in charge of the steriHzing 
apparatus and the preparation of sutures, ligatures, anti- 
septics, and dressings. She is thus responsible for the 
proper condition of these articles. 

Store-room. — Adjacent to the room for sterilizing 
there may be conveniently a storage room in which drugs 
and medicines required, sterile dressings in packages, 
antiseptics, and other supplies may be kept. The nurse 
in charge must be careful that this room does not become 
a repository for unused and useless articles. Its shelves 
should be small, kept under lock and key, and its sup- 
plies Hmited strictly to objects of practical value. 

Recovery-room. — On the opposite side of the oper- 
ating-room from the anesthetizing-room there should be 
a room in which patients may recover from the anesthetic 
after an operation, before they are transferred to a private 
room or ward. In some cases a patient is too ill to be 
immediately moved, and in other cases the operation may 
be so slight that the patient may return to her home 
when she recovers from the anesthetic. This room 
should contain one or two beds, should be well lighted 
and warmed, should contain stimulants, oxygen, and an 
electric battery, and the few instruments required for 
drawing out the tongue and resuscitating the patient 



APPARATUS. 



319 



after an anesthetic. Hot-water bottles or hot cans should 
be available in this room, with a plentiful supply of hot 
water. 

Doctor's Dressing-room. — At a convenient distance 
from the operating-room there should be a dressing-room 
and room with bath for the use of the attending physi- 
cian. This should be furnished with the conveniences of 
a dressing-room. 

APPARATUS. 

Sterilisers. — A most important part of operating- 
rooms are the steriHzers. These are selected by those 
who equip operating-rooms with reference to the size 
and sort of steriHzer, and also with regard to the question 
of steam or the use of gas as a means of sterilization. A 




Fig. 80. — Schimmelbusch's sterilizer for boiling- instruments in soda solution (Fowler). 

nurse placed in charge of such apparatus must endeavor 
to understand the way in which it works, and be espe- 
cially careful that so far as she can bring it about the 
apparatus is kept thoroughly clean and in good condi- 



320 



INTRAPERITONEAL OPERATIONS. 



tion. Several sterilizers are necessary in operating-rooms 
where many operations are performed. There should be 
one for instruments, one for dressings, and one for linen 




Fig. 8i. — Arnold steam sterilizer 
(Fowler). 



Fig. 82. — Small steam-pressure sterilizer and 
instrument boiler (Fowler). 



and blankets. Each will be equipped with appropriate 
trays or baskets, in which the articles to be sterilized will 
be placed. 

I/inen. — A supply of especially selected linen, in 
addition to antiseptic dressings, must be at hand in each 
operating-room. While but few sheets and pillow-cases 
are needed, still some are required, while the towels used 



APPARA TUS. 



321 



for the physician's hands and sometimes for insertion 
within the abdomen should be made of proper and con- 
venient size. Ordinary sheets and blankets are entirely 
too large for use in surgical operations, and result in 
great inconvenience to the nurses and operators in charge 
of the case. Hence especially selected linen made of 
dimensions desired should be prepared. 

Operating-table. — The operating-table should be 
equipped with an attachment to give the Trendelenburg 




Fig. 83. — Boldt's hospital examining and operating table. Showing an adjustable 
stirrup with strap and a heel stirrup (Ashton). 

posture, which can be operated easily and by simple 
means. Glass and iron are the best materials for the 



322 INTRAPERITONEAL OPERATIONS, 

making of operating-tables, while upon the legs of the 
table rubber tips should be placed. 

Stands, Basins, and Trays. — There should be a 
number of portable stands made of glass and steel, and 
mounted upon rubber wheels or tips, upon which may 
be placed basins, pitchers, trays, and other objects. These 
are usually made for each operating-room in accordance 
with the wishes of the Staff. Basins are usually of agate 
or enamelled ware, occasionally of block tin or of copper. 
Several kidney-shaped basins are very useful, and should 
be made of copper. Trays or pans for instruments are 
of thick glass, porcelain-ware, or agate-ware. The glass 
and porcelain are better. A large glass or porcelain 
bowl in a stand is very convenient to place at the side 
of the operating table, so that the operator may rinse his 
hands in it during the operation. Movable stands should 
be upon rubber wheels. 

Wash-stands. — For cleansing the hands, wash- 
stands so arranged that they are emptied by a pipe 
which does not go to the sewer nor to any other sewage 
pipe are desirable. These wash-stands may have various 
devices for the turning on and off of water. Those in 
which the water can be turned on and off by pressure 
with the foot are most convenient, as in this way the 
hands do not come in contact with any object which is 
not sterile during cleansing. There should be receptacles 
for soap, antiseptics, and sterile nail-brushes. 

Instrument-cases. — These should be constructed 
of iron and glass, the iron being painted with enamel 
paint or nickel plated. They should be kept locked 
when the instruments are not required. Care should be 
taken that the instrument case is completely dry and air- 
tight. In some cases a simple apparatus is inserted 



APPARATUS, 



323 



showing the degree of moisture which may be present 
within the case. 

Oxygen Apparatus. — One or two cylinders con- 
taining ox}'gen, with the apparatus necessary for inha- 
lation, should be at hand. This apparatus should be 
examined at frequent intervals in order that any flaw or 
leakage may be detected. 

Instruments for Transfusion. — Canulae suitable 
for insertion into the veins, sterile rubber tubing, sterile 
glass funnels and scalpel, dissecting forceps, several 
hemostatic forceps, needles, needle-holder, and sterile 
normal salt solution should be constantly on hand for 
the performance of transfusion. It is well to have these 



\ 





Fig. 84. — Instruments and apparatus for saline intravenous transfusion. 

instruments ready in a small sterilizing pan so that they 
can be boiled in a few moments. If sterile salt solution . 
has not been prepared, it may be readily made by using 
a standard solution whose strength is known or by add- 
ing a teaspoonful of salt to a pint and a half of hot water. 



324 



INTRAPERITONEAL OPERA TIONS. 



^^lectrical Apparatus. — In addition to the ordinary 
electric lights a group of these should be placed over the 
operating-table, and small electric lights should be avail- 
able for throwing Hght directly into the abdominal cavity. 
In some cases the operator prefers to wear a small elec- 
tric light upon the forehead, retained in position by a 
band. A Faradic battery should also be at hand in oper- 
ating-rooms. It is sometimes a useful appliance in the 




Fig. 85. 



in thermocautery. 



resuscitation of patients from collapse, hemorrhage, or 
shock. An electric cautery and Roentgen ray apparatus 
may also be available. Electrical appliances for convey- 
ing heat to the body of the patient are most efficient and 
useful. An electrical pad upon which the patient may 



APPARATUS. 325 

lie will furnish equable and constant heat and is of great 
value in severe operations upon debilitated patients. 

Miscellaneous Furniture. — A reliable clock with 
plain face should be at hand, so that the time can be 
seen without referring to watches. For the anesthetizer 
a stool is needed, and a small stand upon which may be 
placed the instruments and stimulants which he may 
need. An irrigator upon a stand and upon rubber wheels 
may be used, although many operators prefer to pour 
fluid into the abdomen from pitchers. Glass jars, wide 
but not very high, with screw tops, are needed for the 
storage of sterile dressings and abdominal pads. If these 
are too high, they are cleaned with great difficulty. Quart 
pitchers of the best quality of agate-ware should be in 
abundance, and slop-buckets of the same material should 
also be used. If the room is used by several operators 
and there is a considerable difference in height between 
them, a foot-rest or grating may be necessary for the use 
of the shorter men. In some operating-rooms a black- 
board is placed where it can be conveniently seen by the 
operator. This is for certain memoranda regarding in- 
struments, sponges, or pads. Stretchers employed to 
convey patients to and from operating-rooms should 
be well balanced and run smoothly upon rubber-tired 
wheels. A stretcher should be sufficiently large so that, 
if desired, a patient may be anesthetized on it. There 
should be no chairs in operating-rooms. No one has 
occasion to sit in an operating-room except the anes- 
thetizer, and for him a stool is provided. An unneces- 
sary number of tables should also be avoided, because 
tables, chairs, large cases, cupboards, and closets further 
the accumulation of articles which may collect dirt and 
infection. If those who use the operating-room study 



326 INTRAPERITONEAL OPERATIONS. 

the pathology of their cases, they may desire a sterile jar 
containing formaldehyd solution to be kept in readiness, 
in which tumors can be placed so soon as removed. A 
rack of sterile culture -tubes containing suitable media, 
with a platinum wire for inoculation, is also useful for 
bacteriologic examination. 

PREPARATION OF OPERATING=ROOM AND FURNITURE. 

To prepare an operating-room and furniture for use, 
it should be thoroughly scrubbed with green or brown 
soap and hot water, rinsed, scrubbed with solution of 
sodium bicarbonate and rinsed with hot water, and fumi- 
gated with formaldehyd and well aired. Some prefer 
scrubbing with lysol or carbolic acid, and some use 
mercuric chlorid, although this substance attacks metal 
furnishings and ruins plating. 

IMPROVISED OPERATINQ=ROOM IN PRIVATE HOUSE. 

Where it is necessary to improvise an operating-room 
in a private house a large, airy, and sunny room must be 
selected. Such must have no communication with the 
sewer, nor must it be immediately next a bath-room or 
closet. It should be ventilated, if possible, by an open 
fire with a large flue. From this room the carpet and 
hangings should be removed. All superfluous furniture, 
especially upholstered furniture, should be taken away. 
The floor and woodwork should be thoroughly scrubbed 
with scrubbing-soap or green soap and hot water, with 
solution of soda, with mercuric chlorid (i : 1000) or lysol 
(i per cent.). The nurse should place in the room such 
articles as will be required. The room should then be 
closed and thoroughly fumigated with formaldehyd. In 
this manner the room and its furniture are made as 
aseptic as possible. Before operation the room should 



IMPROVISED APPARATUS. 327 

be well aired and suitably warmed. To prevent inspec- 
tion, cheese-cloth may be stretched over the lower 
windows, or soap may be daubed on the glass. 

IMPROVISED APPARATUS. 

New agate-ware basins are best. China- and earthen- 
ware may be used \{ they be thoroughly scrubbed, rinsed, 
and again scrubbed with bichlorid solution. It is seldom 
possible to obtain agate-ware pitchers in private houses, 
and earthen-ware toilet pitchers may be used if suitably 
cleansed. A new wash-boiler answers an excellent pur- 
pose as a sterilizer if none other is available. A large 
new kettle may also be used. Old linen should be torn 
into convenient size and thoroughly sterilized by boiling. 
Flannel for bandages may be similarly prepared. Unless 
ample time is given in which to prepare towels, unless 
they are thoroughly clean before boiling, they may be 
viewed with suspicion. It would be better to prepare an 
abundance of cheap sterile cheesecloth rather than to 
trust to towels. Cheesecloth may be made ready for 
this purpose by soaking it in a i per cent, solution of 
soda, thoroughly boiling it for one hour, rinsing it, and 
if it is desired to impregnate it with mercuric chlorid, 
soaking it in a solution of i : 2000 or i : 1000. It may 
then be wrung out and dried, when it is available for use. 
An operating-table may be improvised with a kitchen- 
table, and smaller tables and stands required should be 
selected. As they cannot be scrubbed if varnished, they 
should be covered at the time of operation with linen or 
cheesecloth wrung out of bichlorid solution (i : 1000). 
The nurse should impress upon the family the fact that 
while preparing for the operation and during the opera- 
tion an intelligent person must keep a good fire in the 
range or stove, so that hot water may be ready in abund- 



328 INTRAPERITONEAL OPERATIONS. 

ance. If jars are required and cannot be readily obtained, 
new clean butter-crocks which have never been used 
may be readily prepared, and serve a useful purpose. 
If there is not an abundance of pitchers, sterile water 
may be stored in these, the crocks being covered by 
sterile or bichlorid gauze. Several new clean pails or 
buckets should also be available. This apparatus is to 
be prepared by thorough scrubbing, and then by fumiga- 
tion in the operating-room. 

DRESSINGS AND SOLUTIONS FOR CASES IN PRIVATE 
HOUSES. 

It is usually necessary for the nurse to be with her 
patient for several days in a private house before an 
operation. This gives ample time for preparation, which 
the nurse may utilize for sterilizing suitable material for 
dressings. The doctor may prefer to bring with him 
dressings properly prepared. 

EMERGENCIES IN PRIVATE HOUSES. 

When sufficient time is given to preparation good 
results may be obtained from operations in private 
houses. The element of risk, however, is distinctly 
greater, while the labor expended in suitable preparations 
for an operation in a private house is rarely appreciated 
or realized by any one but the nurse and operator. 
Cases are occasionally seen in which some very grave 
emergency arises, for which a patient must be operated 
upon in a private house as soon as possible. Here the 
best that the nurse can do will be to prepare the site of 
operation as promptly and thoroughly as possible, to 
to have on hand an abundance of boiled water, and to 
try her best that all which comes in contact with the 
patient shall be thoroughly clean. 



CHAPTER VIII. 

IMMEDIATE PREPARATION FOR OPERATION. 

STERILIZATION OF THE HANDS OF PHYSICIANS AND 
NURSES. 

A NUMBER of methods are available for the sterilization 
of the hands. No one can be said to be entirely satis- 
factory, but several are practically successful and have 
borne the test of considerable experience. The methods 
most used are the following : 

That of Fiirbringer is essentially as follows : After 
thorough preliminary cleansing of the nails and scrub- 
bing the hands and arms with soap and water and rinsing 
in boiled water, the hands and forearms are immersed in 
absolute alcohol for one minute, and are then rapidly 
transferred while wet to a hot solution of mercuric 
chlorid (i : looo), and thoroughly scrubbed with a nail- 
brush. This scrubbing must be kept up for not less than 
one minute, the nails being especially cleansed. When 
the hands and forearms touch an object not aseptic, they 
must again be immediately washed in bichlorid solution. 

Another method is that of Schatz, which has been 
extensively used and described by Kelly. This method 
is used by him as follows : The hands and forearms are 
vigorously scrubbed with a good nail-brush, with brown 
kitchen soap or green soap and hot water, for ten min- 
utes. The nails must be cut short, and the spaces between 
the fingers and the nails must receive especial attention. 
The water should be changed several times in which 

329 



330 IMMEDIATE PREPARATION FOR OPERATION. 

this scrubbing is done. From ten to five minutes are 
requisite for this scrubbing. The hands and forearms 
are next immersed in a hot saturated solution of potas- 
sium permanganate until stained a deep-mahogany color. 
They are then immediately transferred to a saturated 
solution of oxalic acid as warm as it can be conveniently 
borne. This decolorizes and sterilizes them. The oxalic 
acid can be removed by rinsing the hands in warm water 
or in sterilized lime-water, which at once neutralizes the 
acid. Should the hands or arms come in contact with 
objects not sterile, vigorous scrubbing for ten or fifteen 
seconds with a fresh brush is necessary. 

A third method is that employed by the surgeons of 
the New York Hospital, and practised and stated by 
Keen as follows : Scrub thoroughly with hot water and 
green soap, cleaning about and beneath the nails. A 
scant tablespoonful of commercial chlorid of lime is put 
in the palm and a piece of sodium carbonate one inch 
wide and one and a half inches thick. A little water is 
added to make a thick cream. This is rubbed into the 
palms, hands, and arms until it is perfectly smooth and 
there is a sense of coolness in the palms. It should be 
well rubbed under and around the nails. From three to 
five minutes are necessary for this. The hands are then 
washed with sterile water. If any odor persists, it may 
be removed by a dilute solution of ammonia-water. 

In the experience of the writer the following method 
of caring for the hands and sterilizing them has proyed 
satisfactory. Daily attention by those who operate or 
assist should be given to the care of the hands. The 
nails should be kept of proper length, hang-nails should 
be carefully trimmed out, and all roughened or unhealed 
surfaces should be detected and remedied. Persons 



STERILIZATION OF THE HANDS. 33 1 

dififer with regard to the susceptibility of the skin to dif- 
ferent antiseptics. Thus some persons can use bichlorid 
solutions with but little irritation, while others are unable 
to do so. If there is a tendency to roughness or abra- 
sion, an application may be made each night before 
retiring of some simple antiseptic ointment or lotion, 
such as bay rum and glycerin (equal parts), or lanolin to 
which has been added boric acid (ten grains to the ounce). 
If the hands stain the bed-clothing, cotton gloves may be 
worn, which can be cleansed by boiling. The selection 
of nail-brushes is a matter of importance with regard to 
the cleansing of the hands. Good brushes are simple in 
construction, not too large, and with stiff and efficient 
bristles. Some forms of grass are used in place of bristles, 
and make excellent nail-brushes. Nail-brushes should be 
sterihzed by thorough boiling, and when not in use 
should be kept in a solution of carbolic acid (2 per cent.) 
or lysol (i percent.). Cheap brushes are quite sufficient, 
and should be burned after each septic or doubtful case. 
In cleaning the nails a sharp blade should not be em- 
ployed. This roughens the under surface of the nail 
and favors the accumulation of dirt. The nails should 
be cleaned with a smooth point of ivory, pearl, or wood. 
Sticks of orange-wood are very useful for this purpose. 
In brushing the hands the fingers must be separated as 
widely as possible, and the spaces between the fingers 
receive especial attention. 

It is our habit to scrub the hands and forearms thor- 
oughly, after the nails have been suitably prepared, with 
green soap and hot water, this scrubbing to last between 
five and ten minutes. It is not so much the number of 
minutes as the thoroughness of the scrubbing which is 
essential. The hands and arms are then scrubbed in hot 



332 IMMEDIATE PREPARATION FOR OPERATION. 

sterile water with a separate and sterile brush. They are 
then scrubbed in alcohol and quickly transferred to a 
solution of mercuric chlorid (i : looo) and scrubbed 
again. They are then thoroughly rinsed in alcohol a 
second time, and just before the abdomen is opened are 
scrubbed again in hot normal salt solution. 

Gloves. — The introduction of gloves by Halsted and 
Mikulicz has given us a very convenient resource in sep- 
tic and doubtful cases. Cotton or thread gloves have 
been tried, but are not as satisfactory as rubber gloves. 
These are of two kinds, the seamed and the seamless. 
The latter are preferable. Well-made rubber gloves 
may be sterilized by boiling, and with good care will 
last for a considerable time. Oily substances and alka- 
Hes should not be applied to rubber gloves. When not 
in use they should be thoroughly dried by turning inside 
out, and sterilized gauze may be packed into the fingers 
and palm to prevent a possible sticking together of the 
surfaces. When the gloves are to be used many opera- 
tors prefer to put them on when thoroughly dried ; others 
fill them with an antiseptic solution, raising the hand and 
allowing the solution to escape as the glove is put on ; 
while others lubricate the hand with sterile glycerin 
before applying the glove. If the hands are sensitive, 
the sterile glycerin is very healing. A nurse who assists 
at operations should accustom herself to the use of 
gloves, as many operators prefer that those nurses who 
touch dressings, sutures, or instruments should wear 
them. 

ANTISEPTIC COVERS FOR JARS AND TABLES. 

To maintain asepsis, we must not only cleanse the 
hands, but we must also avoid touching objects which 



PREPARATION OF ABDOMEN AND VAGINA. 333 

are not aseptic. In an emergency it is often necessary 
to open a jar containing dressings or surgical supplies 
the cover of which is not aseptic. Danger may be pre- 
vented by touching such a cover with a pledget of bi- 
chlorid gauze, which the nurse takes in her hand before 
she approaches the jar. If jars and tables be covered 
with wet bichlorid gauze just before the operation, the 
nurse can lift off the cover of the jar or touch the top of 
the jar without danger. In some operating-rooms a 
nurse whose hands are not sterile but thoroughly clean 
is kept in the operating-room during an operation, to 
touch and handle such objects as are not sterile. She is 
sometimes called in joke ''the dirty nurse." 

PRELIMINARY PREPARATION OF THE ABDOMEN AND 
VAGINA. 

On the day before the operation, or earlier if the 
physician orders, the surface of the abdomen, the vagina, 
and the tissues about the labia should be suitably pre- 
pared. As this is a very responsible matter, the physi- 
cian should give the nurse written directions or should 
dictate them to her for this procedure. Patients differ 
considerably in the ease or difficulty with which the sur- 
face of the body can be made aseptic. In fat patients 
the folds of the tissues about the groin and the deep 
umbilicus make preparation very difficult. In persons 
with sluggish, greasy skins it is also a hard matter to get 
them clean. In thin persons with rather delicate skin 
the task is much more easy. Especial attention in cleans- 
ing must be given to the umbilicus and to the groin and 
pubes. The pubic region should be shaved, and the 
region of the vulva should be shaved or have the hair 
closely clipped. Having thoroughly cleansed her own 



334 IMMEDIATE PREPARATION FOR OPERATION. 

hands, and placing the patient in the dorsal position with 
the thighs flexed, the nurse should thoroughly scrub the 
anterior surface of the body from the tip of the breast- 
bone downward to the middle of the thighs with green 
soap and hot water, using a good nail-brush and taking 
at least ten minutes for this scrubbing. The inner aspect 
of the thighs, the groins, the pubes, and the tissues about 
the vulva and labia should be especially thoroughly done. 
If the brush cannot be borne in sensitive portions, 
pledgets of gauze or cotton may be used for scrubbing, 
held in dressing-forceps or in the hands. In cleansing 
the umbiHcus small bits of cotton should be carried well 
into this portion of the body, and the parts should be 
thoroughly scrubbed by rotary motion. When these 
surfaces have been rinsed in warm boiled water they 
should then be cleansed with alcohol or with ether, and 
then with mercuric-chlorid solution (i : looo). A large 
pad or dressing of mercuric-chlorid gauze should then be 
firmly and smoothly bandaged upon the abdom^en and 
thighs by a broad flannel bandage. If the vagina is to 
be prepared, it should be done by scrubbing with pledg- 
ets of cotton with green soap and hot water or tincture 
of green soap, followed by copious douching with hot 
water, and then with mercuric-chlorid solution ( i : 2000) 
or lysol (i per cent.). Before making this preparation 
it is well to empty the intestine thoroughly by a copious 
enema. In cases in which the skin is excessively thick 
and oily some operators have appHed to the abdomen 
several nights before the operation a poultice or paste of 
green soap. This is removed on the following day and 
the preliminary cleansing carried out. 



FINAL PREPARATION, 335 



FINAL PREPARATION. 



Just before the operation, and often while the patient is 
anesthetized, the abdomen is again scrubbed thoroughly 
with green soap and hot water, rinsed with hot sterile 
water, cleansed with alcohol or ether, mercuric chlorid, 
and hot sterile water. The vaginal cleansing is again 
repeated at this time. 

Cathetemation. — Before the patient's limbs are 
secured to the Trendelenburg attachment of the table, 
and at the time when the final preparation is made, the 
patient should be catheterized with a sterile glass or soft- 
rubber catheter. The tissues about the meatus should 
be thoroughly cleansed with sterile water and bichlorid 
solution (i : 2000). 

The Rectum. — At this time the rectum should be 
copiously douched with normal salt solution, and the 
rectal tube allowed to remain until the fluid has escaped. 
In some cases operators prefer to have several ounces of 
the normal salt solution left in the rectum for absorption. 

Sterile Coverings. — The anterior surface of the 
body should be entirely covered by sterile material ; the 
leggings put upon the lower extremities should have been 
sterilized, sterile towels should be placed over the chest 
and at the sides of the body, and over the surface of the 
abdomen should be laid a broad sheet of sterile gauze. 
,Some operators prefer that this be made in several thick- 
nesses lightly quilted together. Before opening the 
abdomen the operator will make an incision into this 
gauze with sterile scissors, exposing a surface sufficiently 
large for his purpose. 

Placing the Patient upon the Table. — Before the 
final preparation and the application of the sterile cover- 



336 IMMEDIATE PREPARATION FOR OPERATION. 

ing the patient is placed upon the operating-table, and 
when the final preparation is complete the limbs are 
bandaged to the Trendelenburg attachment of the table 
and the patient is placed in proper position. The shoulder 
supports should be carefully adjusted, and if they are 
efficient, it may not be necessary to tie the limbs. It is 
essential that the arms be protected from injury if the 
patient is to be in the Trendelenburg posture. The fore- 
arms should be bent upon the arms and the hands carried 
up to the region of the shoulders, where the sleeve of 
the patient's jacket may be pinned to the side of the 
jacket. The arms should not be put in a constrained 
position, and care should be taken that the arms do not 
fall under the raised portion of the operating-table. Such 
an accident has happened, and when the table was let 
down the arm has been severely bruised by the table. 

Counting Pads, Sponges, and Instruments. — 
While the patient is being prepared, the instruments, 
having been sterilized by boiling, are placed by the first 
assistant in sterile trays, and are covered with sterile 
w^ater, normal salt solution, or i per cent, solution of 
carbolic acid. These trays are placed upon a suitable 
stand within convenient reach of the operator and assist- 
ants. The nurse in charge of pads, sponges, and instru- 
ments should be sure of the number of pads, sponges, 
needles, and hemostatic forceps which are employed. It 
is a good plan to put upon the blackboard the title of the 
operation, the date, the hour, the number and kind of 
pads, sponges, hemostatic forceps, and needles employed. 
If this is not done, the nurse should make a list of 
them and place the list before her where she can read- 
ily see it. 

Arrangement of Apparatus. — The instruments 



THE ANESTHETIZER — PHYSICIANS' CLOTHING. 337 

being placed in position, a large bowl of normal salt 
solution or sterile water is placed in convenient position 
for the operator in rinsing his hands. Needles, sutures, 
and ligatures are put upon a stand in charge of a nurse 
or assistant. Sponges and pads are handed by a nurse, 
while the nurse in charge of the dressings is ready to 
furnish strips of gauze for packing or dressings as may 
be required. Normal salt solution for irrigation should 
be ready in abundance at any temperature. The ap- 
paratus for giving oxygen, the electric apparatus and 
cauterizing apparatus, if such be desired, should be in 
constant readiness. Apparatus for hypodermoclysis or 
for intravenous transfusion should be at hand. Suitable 
nozzles for injections into the rectum, with syringes, must 
also be ready. 

THE ANESTHETIZER. 

The anesthetizer should have within convenient reach 
a stand with two shelves. Upon the upper should be a 
mouth-gag, forceps for drawing out the tongue, a collec- 
tion of stimulants in a small case in plainly labelled 
bottles, and a good hypodermic syringe ready for use. 
On the under shelf of the stand may be a kidney-shaped 
basin in case the patient should vomit. A half dozen 
soft towels should be also available. 

PHYSICIANS' CLOTHING. 

Physicians are accustomed to wear at operations 
trousers, shirts, caps, and gowns of material which can 
be readily sterilized. To cover the entire face, caps are 
made with pieces going over the face in which apertures 
are cut for the eyes. The mouth and nostrils are usually 
left covered to prevent contamination from the expired 
22 ^ 



338 IMMEDIATE PREPARATION EOR OPERATION. 



air, and also from mucus in the nose and throat of the 
operator. Some physicians prefer not to use the complete 
face-mask, but to have a small piece of gauze tied over the 
mouth during the operation. 
In some instances attempts 
have been made to sterilize 
the shoes worn by operating 
surgeons. Such garments 
should first be washed thor- 
oughly in the usual manner 
and then be sterilized with 
sheets and blankets. A suit 
should be placed together, 
pinned in a sterile towel and 
suitably labelled, so that the 
physician may find it in readi- 
ness for any operation. Such 
packages should be placed in 
the dressing-rooms for the 
Staff. 

DRESS FOR NURSES. 

Dresses worn by nurses in 
operating-rooms should be 
washed and sterilized after 
each operation. The nurse 
should wear shoes which give 
her a sure and easy tread. 
Felt slippers in which cork 
soles are placed, or rubber- 
bottomed canvas shoes, known as *' sneakers," with cork 
insoles, are useful. Under no circumstances should nurses 
in operating-rooms wear heavy and noisy shoes. As the 




Fig. 86. — Surgeon's operating suit. 



DISCIPLINE OF THE OPERATING-ROOM. 339 

floors of such rooms are smooth and may be wet and 
slippery, the nurse might fall and injure herself if she 
were not provided with suitable shoes. Many operators 
prefer to have nurses abandon the usual cap, and wear in 
its place a cotton or linen skull-cap covering as much as 
possible of the hair. Sterile gowns should also be in 
readiness for the nursing staff of an operating-room, and 
clean rubber aprons may be worn beneath the sterile 
gown if needed. Rubber aprons are not comfortable, 
however, but very hot, and nurses usually prefer to avoid 
them if possible. 

DISCIPLINE OF THE OPERATINQ=ROOM. 

The clinic nurse or nurse in charge should be in abso- 
lute control of the nurses. Next to her in responsibility 
are the nurses who prepare the patient and have charge 
of the sponges, pads, hemostatic forceps, and needles. 
Each nurse who has anything to do with an operation 
has a great and decided responsibility, and must be im- 
pressed with this fact. To each a definite duty must be 
assigned, and she must be held strictly responsible for the 
performance of such duty. It may be necessary for the 
nurse in charge to inspect the hands of the others from 
time to time to see that they are in proper condition. 
The smallest number of nurses who can do the work 
will succeed far better than too many. Talking has no 
place during an operation, and only necessary communi- 
cations should pass between nurses at such times. In 
addition to the nurses, an orderly may be very useful in 
an operating-room. Such a man should be, if possible, 
habitually sober. He should be under good discipline, 
and impressed with the fact that he is to touch nothing 
unless ordered to do so. He should wear noiseless shoes 



340 IMMEDIATE PREPARATION EOR OPERATION. 

and duck trousers and jacket. He may assist in lifting 
patients, in managing the stretcher, in emptying buckets, 
and in lifting any considerable weight. He should be 
under the orders of the chief nurse. The orderly may 
also swab and clean the floor, walls, ceiling, and furni- 
ture of the operating-room, if he does this under the 
immediate supervision of a reHable person in the nursing 
staff. 

TRAINING OF NURSES IN OPERATIVE W0R4C. 

To train nurses efficiently in this work, they may re- 
ceive verbal explanations and instruction in classes and 
in personal lessons from the chief nurse. They should 
receive demonstrations regarding the growth of bacteria, 
and become impressed with the fact that these organisms 
exist and are living beings. They should have a simple 
and brief account of various operations, and should be 
carefully taught in the symptoms of hemorrhage and 
septic infection. They should be first allowed to attend 
operations as spectators, and thus become accustomed to 
the sight of blood and have ample opportunity to faint 
several times without incommoding the operator or the 
operation. Pupil nurses may next be advanced to helpers, 
when they fetch and carry to other nurses without touch- 
ing sterilized articles. They may then assist the anes- 
thetizer, and may gradually be entrusted with the prep- 
aration of solutions, the care of ligatures and pads, and 
the preparation of patients. Like all other branches of 
nursing, some display for such work far greater aptitude 
than others and are more successful in it. The nurse 
who is easily excited and confused, and who is naturally 
inaccurate in her performance of duty, is not fitted for 
this branch of nursing. 



CHAPTER IX. 

AFTER THE OPERATION. 

It is customary with many operators to have the pulse 
and temperature taken almost immediately after an opera- 
tion. The patient is removed from the operating-table 
to her bed, which is suitably warmed by hot bottles and 
in which are hot bottles placed about the feet. If there 
is much shock, she may be permitted to lie between 
blankets, with the head low, turned on one side, the 
limbs extended or flexed, a large firm roll being placed 
beneath the knees. The room should not be too light, 
but not so dark that the color of the patient's face can- 
not be seen and her symptoms noted. The nurse who 
is to take charge of her after-treatment assumes control 
from the time the patient is placed in bed, and becomes 
responsible for her, 

ARRANGEMENT OF THE PATIENT'S ROOM. 

By some simple precautions the work of the nurse 
may be much facilitated and the comfort of the patient 
enhanced by a suitable arrangement of her room. It 
should be ventilated by an open fireplace and large flue ; 
if the temperature demands it, an open fire should be 
kept constantly burning. A large screen is a most use- 
ful article, and should be placed between the patient's 
bed and the door. This makes it possible for supplies 
to be brought into the room unseen by the patient. Two 
screens are sometimes useful, one in front of the door 
-^ 341 



342 AFTER THE OPERATION, 

and one in front of the window. Both protect the patient 
from disturbance, and add considerably to her comfort 
and that of the nurse. One or two firm small tables or 
stands are needed. Apparatus for heating water in small 
quantities is very desirable, and a gas jet or Bunsen 
burner may be utilized for this purpose. The nurse 
should have a comfortable chair by the bedside, so that 
when her patient is quiet and dozes she may rest also. 
Servants or assistants should wait upon the nurse 
promptly, bringing her those articles desired and remov- 
ing what must be taken away promptly. The nurse 
should have means of summoning aid at any time. 

VOMITING. 

If the patient be well prepared for operation, the ten- 
dency to vomiting is much lessened. Some operators 
have the patient's stomach washed out while still upon 
the operating- table, just before she recovers conscious- 
ness from the anesthetic. This is an excellent precaution 
and usually very efficient. Anesthetizers often place 
over the nostrils and mouth of the patient a piece of 
sterile gauze saturated in vinegar. This is said to lessen 
very much the tendency to vomiting and aid in the 
prompt return of the patient to consciousness. If vom- 
iting occurs, the nurse should support the forehead of 
the patient with one hand, raising the shoulders slightly. 
Hot water in sips is allowed by most operators, and the 
patient may take sufficient so that she vomits easily and 
without straining. While vomiting is undesirable, retch- 
ing is far worse, and the free taking of hot water may 
stop the latter by making the former easy. A nurse 
must have a small basin to receive the contents of the 
patient's stomach, and this should be emptied and placed 



HEMORRHAGE AND SHOCK. 343 

out of sight as soon as possible. Towels or napkins 
soiled by vomiting should be removed immediately. If 
vomiting be severe and uncontrollable by simple methods 
such as described, the physician must be notified, when 
he will prescribe appropriate treatment. He may order 
a mustard plaster or paste put over the pit of the stom- 
ach, a hypodermic injection of an anodyne, the rectal 
injection of a stimulant or sedative, the washing out of 
the stomach, or the administration by the stomach of 
medicine intended to empty the intestine. The attempt 
is sometimes made to control vomiting by the adminis- 
tration of bits of ice or iced champagne in teaspoonful 
doses. The writer's experience has not been favorable 
to this method of treatment. In our observation the use 
of ice distinctly predisposes to the occurrence of vomiting. 

HEMORRHAGE AND SHOCK. 

Within the first few hours after the conclusion of an 
operation signs of hemorrhage and shock may become 
apparent. The patient's pulse is rapid, feeble, and easily 
compressed ; the breathing is sighing, panting, irregular, 
and with the upper chest ; the color is pallid ; the skin 
clammy ; the patient complains of faintness, thirst, dim- 
ness of vision, restlessness, and often has pain in the ab- 
domen. This array of symptoms should lead the nurse 
to send at once for the physician. She can do little 
intelligently before his arrival, because the danger is 
that the patient is bleeding from some vessel in the ab- 
dominal cavity, and that free stimulation which she might 
use would increase the flow of blood. Until the doctor 
arrives the nurse may place external heat about the 
patient's body, and quietly and without manifesting alarm 
may have preparations made for reopening the abdomen. 



344 



AFTER THE OPERATION. 



If the case occurs in a hospital, the chief nurse and nurse 
in charge of the operating-room must be notified at once. 
They will immediately have the operating-room warmed, 
summon the Staff, and make ready as quickly as possi- 
ble. If the case be in a private house, the nurse must 
see that hot water in abundance is ready, that sterile 
gauze is prepared, and she must plan exactly what she 
will do if the physician determines to reopen the abdo- 
men. 

The Treatment of Hemorrhage after Abdom- 
inal Section. — In most cases the abdomen must be 
opened and the bleeding vessels caught and tied. At 
the same time the blood-vessels of the patient must be 
freely supplied with a circulating fluid to replace the 
blood which has been lost, as otherwise the heart will 
cease to beat. The reopening of the abdomen is accom- 
panied or preceded by intravenous saline transfusion. 
Accordingly the nurse must be ready to prepare salt 
solution at a moment's notice in such a case. If the 
physician has the apparatus with him, he may open a 
vein, while otherwise he may practise hypodermoclysis 
of salt solution or direct the nurse to inject as much hot 
salt solution as possible into the patient's bowel. The 
reopening of the abdomen should be done as promptly 
as possible, clots turned out, the bleeding vessel tied, and 
the abdomen filled with hot salt solution. If this be not 
in readiness, boiled water will be used. When the 
wound is closed and dressings again applied the physician 
will use every means to bring about a favorable reaction. 

The patient will be placed in bed with artificial heat 
about her, the foot of the bed will be raised at least four 
feet from the floor, hypodermic injections of stimulants 
will be given, and the limbs of the patient may be band- 



HEMORRHAGE AND SHOCK. 345 

aged. The nurse will be instructed to inject into the 
rectum normal salt solution (from six to eight ounces), 
or freshly made hot coffee (two ounces), whiskey (two 
ounces), and hot water (two ounces) ; while salt solution 
may be injected beneath the skin. If available, an 
electric battery may be used to stimulate respiration and 
the action of the heart. 

Hemorrhage after abdominal section is a most serious 
complication. In a few cases the conditions are such that 
the operator does not think best to reopen the abdomen. 
He may believe that the patient's best chance lies in 
absolute quiet, stimulation, and the gradual formation of 
a large clot. But no matter whether the abdomen be 
opened or not, a very short time decides the fate of the 
patient. The nurse, while realizing the gravity of the 
situation, must not show alarm or fear, must keep her 
wits thoroughly in control, realizing the important things 
to be done and anticipating as far as possible the doctor's 
wants. If in a private house, the family naturally will 
be much alarmed, and should not be deceived regarding 
the existence of danger. They should, however, be told 
that there is every hope of a favorable issue. With 
prompt and wise treatment patients are literally rescued 
from death in these cases. 

Care during- Convalescence.— Patients who have 
suffered from hemorrhage after operation require especial 
attention during convalescence. They should be kept 
in the recumbent posture much longer than others, their 
food should be carefully selected, and the most digestible 
and nutritious, and tonic medicines are usually prescribed. 
Massage, salt sponging, inunctions with olive oil, elec- 
tricity, and occasionally the inhalation of oxygen, may be 
employed. The reason for caution in assuming the 



346 AFTER THE OPERATION. 

Upright position lies in the fact that occasionally patients 
who have suffered from hemorrhage form clots about the 
heart if they suddenly assume the upright position, which 
may prove fatal. These patients sometimes suffer 
severely from headaches which are caused by their 
anemic condition. 

SEPTIC INFECTION. 

This complication develops gradually, usually within 
the first forty-eight to seventy-two hours after the oper- 
ation. The abdomen of the patient gradually distends ; 
the temperature falls to normal or below normal, or rises 
to 103° or 104° F. The pulse steadily rises to no, 120, 
130, and in fatal cases still higher. The tongue is dry 
along the center, often brownish in color, and the mouth 
and lips are sometimes dry. The patient may complain 
of no especial pain, is apathetic, listless, without appetite, 
often thirsty, and very rarely aware of her dangerous 
condition. In some cases acute abdominal pain is 
present. The skin may be leaky, a constant and 
clammy perspiration being present. Chills may be dis- 
tinctly detected, or the patient may never have a well- 
pronounced chill. The bowels will not move in spite of 
injections or medicines, or a profuse and sometimes fetid 
diarrhea is present. 

The treatment of this condition varies in different cases. 
The physician will purge the patient freely, endeavoring 
to move the bowels copiously by injections. If vomiting 
be present, the stomach will be washed out, the patient 
will be stimulated very freely, the wound will be redressed 
and carefully examined, and the abdomen may be re- 
opened. For the reduction of fever, sponging, the use 
of a large abdominal ice-bag, and cold packs may be 



SEPTIC INFECTION. 347 

employed. If delirium and restlessness develop, seda- 
tive medicines will be given, often by hypodermic injec- 
tion. 

If the patient's stomach can retain food, liquid nourish- 
ment will be given in small quantities at frequent inter- 
vals. If nothing is retained, an effort will be made to 
feed and stimulate by the bowel. 

If the course of the infection is not rapid, the patient 
may develop bed-sores, abscesses in the line of incision 
and abdominal walls, while abscesses in other portions 
of the body may also form. 

The responsibility of the nurse in cases of septic in- 
fection after operation rests primarily in detecting the 
condition promptly and reporting it at once. The physi- 
cian is responsible for the treatment, in which the nurse 
can do much by faithfully and intelligently following his 
orders. 

In some septic cases constant rectal irrigation is prac- 
tised. This is done by inserting a medium-sized catheter 
into the bowel, to which is attached a fountain-syringe, 
or other receptacle, for fluid. This is hung just suffi- 
ciently high above the patient to cause the fluid to pass 
very gently, but constantly, into the bowel for absorp- 
tion. Normal salt solution is usually employed, and 
this entering by the bow^el is absorbed, and makes its 
way out of the body through a drainage-tube, or gauze 
drain, placed at the lower end of the abdominal incision. 
By this means a constant irrigation and drainage of the 
abdominal lymphatics is secured. 

A septic patient usually shows signs of infection in 
some portion of the skin. Bed-sores form very rapidly in 
these cases, as the vitality of the tissues throughout the 
entire body is gradually diminished. Especial care is 



348 AFTER THE OPERATION. 

necessary to maintain the skin in good condition. In 
some cases where inflammation of the veins is present, the 
skin over the veins may become enormously stretched, 
the superficial layers may die, and the tissue become 
infected. Sloughing sometimes extends to the subcu- 
taneous tissues, requiring incision and drainage. In all 
septic patients the nurse should be on the lookout for 
skin lesions, should report them promptly to the attend- 
ing physician, and remember to follow faithfully his 
directions concerning their care. By keeping such lesions 
cleaned and as aseptic as possible, much comfort will be 
given to the patient, and her dangers will be considerably 
lessened. 

Septic patients are rarely normal in mental condition. 
Some become delirious during the fever, while many of 
the most dangerous and fatal cases show perfect indif- 
ference to their surroundings. It is, in fact, always a 
dangerous symptom when a septic patient asserts that 
she has no pain or distress, but feels excessively wearied 
and cannot rouse herself to take interest in anything 
about her. Many patients who are not fatally ill become 
greatly depressed and even melancholy. It is the nurse's 
duty to always encourage these patients in every way in 
her power, assuring them that all possible will be done 
for them, and giving them every hope of prompt recovery. 
Where such patients are actively delirious it may even be 
necessary to restrain them by bandages. 

It is of the utmost importance that septic patients take 
an abundance of food and stimulants. No one but the 
nurse can manage this successfully, and great skill is 
sometimes necessary. The nurse should never ask the 
patient what she wants to eat, or whether she will take it 
or not, but as nearly as possible, at regular times, the 



SEPTIC INFECTION. 349 

nurse should bring the food, prepared, and tell the patient 
kindly but firmly to take it. If the patient sleeps well, 
she may go an hour or two over the usual time for food. 
Stimulants are also needed in these cases, and frequently 
in large quantities. When stimulants do good, the 
patient is more quiet, with better pulse and somewhat 
lower temperature after their administration. If stimulus 
is assimilated the patient does not become intoxicated, no 
matter what quantity is taken. The fever is reduced by 
sponging or packing; the patient is usually refreshed 
when the temperature drops, and will then take food and 
stimulants. When the fever is very high patients will 
often take neither. The nurse must watch her oppor- 
tunity, first, to reduce a very high temperature by the use 
of cold, and then to cause the patient to take food and 
stimulants. Neither food nor stimulants should be left 
long in the patient's room where she can see them. The 
sight of these objects frequently causes considerable 
disgust. 

In nursing septic patients it must be remembered that 
the patient may infect the nurse. Abrasions on the hands 
are especially dangerous to the nurse, and rubber gloves 
should be worn in dressing septic patients and in all 
manipulations about suppurating wounds. In practising 
irrigation or douching, care must be taken that fluid does 
not spatter into the nurse's face, and especially into the 
eyes. Infection of a serious nature may result. 

Before taking another case after nursing a septic 
patient, the nurse must disinfect herself most thoroughly 
and see that her clothing has been repeatedly sterilized. 
It is well, if possible, not to take another patient after 
nursing a septic case until several weeks have been passed 
as much as possible in the open air. 



350 AFTER THE OPERATION. 

RESTLESSNESS AND THIRST. 

Few patients have abdominal section without suffering 
more or less from these disagreeable consequences. The 
temperament of the patient and the condition of the 
nervous system at the time of the operation are very 
clearly shown by the patient's behavior afterward. If a 
patient has been accustomed to indulge freely in stimu- 
lants of any sort, if she is naturally nervous, irritable, 
uncontrolled, freaky, and irresponsible, she will suffer 
after a serious surgical operation. In some cases the 
patient's suffering from her disease has made the nervous 
system so sensitive that she feels shock very keenly. 
The depressing effects of long-continued pain are strik- 
ingly shown in the behavior of these cases after operation. 
Restlessness and thirst are mentioned together because 
each is largely controllable by the brain. A person who 
is accustomed to exaggerate the natural sensations of the 
body suffers far more from thirst than one who does not. 

In controlling these conditions the mental and moral 
influence of the nurse has great weight. Her constant 
presence, steady watchfulness, and gentle and tactful re- 
straint will help the patient to control herself in a rrieas- 
ure and will lessen greatly her suffering. Cheerfulness 
and hope aid much in producing this result. In a fit of 
restlessness the patient may do herself great harm, and 
hence should not be left alone for one moment night or 
day during the first three days after an operation. With 
the permission of the physician, restlessness may be 
much alleviated by gently kneading the patient's lower 
limbs, supporting the patient's knees by placing beneath 
them a large firm roll. Rubbing the knees gently often 
tends to reheve restlessness. 



ABDOMINAL DISTENTION. 351 

For the relief of thirst patients are ordered hot water 
in sips, and by some operators the use of cracked ice is 
also allowed. The lips and mouth may be gently moist- 
ened with cold water or with glycerin and lemon-juice in 
water. If thirst be severe, from six to eight ounces of 
boiled water may be injected into the recturn every four 
hours. In our experience hot water in sips checks 
thirst much more promptly than any other means. 

If restlessness and thirst are augmented by pain, the 
physician must be notified, when suitable treatment will 
be ordered. It is often necessary to control such patients 
for the first few hours after an operation by the hypoder- 
mic injection of morphin, and no bad results follow such 
treatment. In some cases codein proves useful. 

ABDOMINAL DISTENTION. 

This distressing condition may begin to develop soon 
after the operation, and steadily increase. It may occa- 
sion little suffering or it may give the patient much dis- 
tress. The physician should be notified, and his treat- 
ment will be directed to removing the gas from the 
bowels and preventing its further formation. He may 
order the nurse to pass a soft-rubber rectal tube as high 
into the bowel as possible, allowing it to remain for some 
time for the escape of gas. An enema of one tablespoon- 
ful of spirits of turpentine in one pint of Castile soap- 
suds may be used, or an enema of asafetida may be 
employed. In many cases the physician Vvill begin the 
administration oi purgative medicine if distention of the 
abdomen occurs. Such medicine may be calomel. If no 
result is obtained by the first injection, it may be repeated 
in an hour, and again in an hour, when success may 
folloWo A moderate degree of abdominal distention is 



352 AFTER THE OPERATION, 

not a very dangerous condition, although it is not a wel- 
come symptom to the physician. In obstinate cases the 
bowels and stomach are freely irrigated, purgatives are 
given, stimulants are administered by the mouth or 
hypodermically, and a thorough and persistent effort 
made to remove the gas from the intestines. If nothing 
can be accomplished by these means, a fatal result may 
be feared. The patient may pass gas freely by the 
mouth, but this seems to have little influence in lessening 
the distention of the abdomen. 

FOOD AND STIMULANTS. 

Patients may be fed after operation, and stimulated by 
the bowel or by the mouth. Some physicians give nothing 
for the first twenty -four hours, then beginning gradually 
to feed by the mouth. Others give nutritive and stimu- 
lating enemas from the first until the bowels move, and 
then begin the administration of food by the mouth. For 
administration by the bowel, peptonized milk, two ounces ; 
white-of-egg water, one ounce ; and warm water, two 
ounces, form a useful nutritive enema. A raw ^^^ 
beaten up with two ounces of peptonized milk, to which 
two ounces of water are added, is also useful. One ounce 
of beef-juice in four ounces of warm water may also be 
used. As a stimulant, two ounces of whiskey in four 
ounces of water may be employed. Whiskey, one to 
two ounces, and salt solution, four to five ounces, make 
an excellent stimulating enema. 

If food be given by the mouth, a teaspoonful of pep- 
tonized milk and a teaspoonful of barley-water may be 
administered every hour or two. If this be retained, the 
quantity may be gradually increased to one ounce of pep- 
tonized milk and one ounce of barley-water given every 



THE FIRST MOVEMENT OF THE BOWELS. 353 

two or three hours. If it be thought wise to ^\y& stimu- 
lants by the mouth, the best quahty of whiskey diluted 
with twice its volume of water is usually best. If good 
brandy can be obtained, this is well taken by some pa- 
tients. 

Stimulants are often given by hypodermic injection, 
strychnin and digitahs being the drugs most often used. 
The nurse should be careful to boil the needles repeatedly, 
and to have the solution employed perfectly clear. The 
site of puncture should be prepared by scrubbing with 
soap and water, and then with alcohol. If the nurse be 
exceedingly careful and thorough, no suffering will result 
from hypodermic injections at her hands. When the first 
food by the mouth has been retained, it is often usual to 
add to the nourishment freshly made chicken-broth 
salted and given hot. 

THE FIRST MOVEMENT OF THE BOWELS. 

Usually within forty-eight hours after the operation, 
and in all cases we believe within seventy-two hours, 
the bowels of the patient must be thoroughly emptied. 
Operators differ much in the way in which this is accom- 
plished. Some invariably give calomel in small doses 
often repeated, or in several comparatively large doses. 
It may be combined with sodium bicarbonate or given 
with sugar of milk. Others prefer a saturated solution 
of Rochelle salt or Epsom salt, given in teaspoonful 
doses every hour. After a purgative has been adminis- 
tered by the mouth for a certain length of time an enema 
is often ordered. Glycerin, one to two ounces ; mag- 
nesium sulphate, one to two ounces ; and Castile soap- 
suds, one pint, is an efficient preparation. To this may 
be added a teaspoonful or tablespoonful of spirits of 



354 AFTER THE OPERATION. 

turpentine. Others prefer the enema of Castile soapsuds, 
one pint to one quart ; castor oil or olive oil, one to two 
ounces ; spirits of turpentine, one tablespoonful beaten 
up with the yelk of one raw ^^^, the whole to be thor- 
oughly mixed and administered while warm. In giving 
enemas after operations it is customary to raise the 
patient's hips slightly, turning her a very little upon the 
left side. A folded pillow or blanket is placed beneatn 
the back, a Kelly pad being put beneath the patient so 
that the enema may drain into a bucket at the side of the 
bed. When the condition of the patient is so critical that 
this slight motion cannot be allowed, old linen or oakum, 
or cotton-batting, may be placed about the anus and the 
discharges soaked up in this way. It is rarely, however, 
that the nurse will not succeed in placing the patient upon 
some sort of receptacle. If the first injection does not 
succeed, it is customary to repeat it in one or two hours 
afterward. In some cases the rectal tube may be inserted 
and allowed to remain for an hour or two, favoring the 
escape of gas and fecal matter. As the first thorough 
movement of the bowels is most important, the nurse 
must not despair, but by gentle and repeated trials suc- 
ceed in accomplishing her purpose. If a patient has 
not been ill previously and has not had injections, the 
nurse may have to overcome considerable timidity and 
nervous apprehension on the part of the patient. 

THE USE OF THE CATHETER. 

It is customary to catheterize patients within six or 
eight hours after the operation. Afterward the spon- 
taneous passage of urine is encouraged. A record should 
be kept as nearly as possible of the number of ounces of 



STIMULATION BY THE MOUTH. 355 

urine passed, and a specimen should be set aside for the 
physician's examination. 

INCREASED DIET. 

After the bowels have moved freely the diet of the 
patient is increased in quantity. Chicken-broth, mutton- 
broth, clam-broth or oyster-broth, buttermilk, peptonized 
milk prepared by the cold process, white-of-egg water, 
or wine whey is given in from two to four ounces every 
three to four hours. Any agreeable form of water may 
be administered every alternate three or four hours. If 
there is a tendency to the formation of gas and to slight 
nausea, the use of hot water is especially beneficial. Some 
physicians allow a cup of tea or coffee for breakfast, with 
milk-toast, or a soft ^g^ or junket. The increase in diet 
must be determined by the conditions of each individual 
case, and not by rule or routine. The state of the 
tongue, the condition of the abdomen, the number and 
character of the bowel movements, the pulse, the tem- 
perature, and general vigor, must all be considered in 
deciding to increase the patient's diet. 

STIMULATION BY THE MOUTH. 

Stimulation by the mouth is often necessary in cases 
in which shock or hemorrhage has been present. 
Strychnin given with liquid nourishment is commonly 
used. Alcohol combined with nutritious material or 
well diluted with w^ater may also be administered. 
Should septic infection be present, the quantity of alcohol 
given will be limited only by the patient's power to ab- 
sorb it. In critical cases stiumulus must be given hypo- 
dermically. Str^xhnin, digitalis, and atropin are the 
drugs most commonly employed. 



356 AFTER THE OPERATION. 

CHANGES OF POSTURE. 

A patient after abdominal section must remain as quiet 
as possible for the first few days. If the patient does 
well, slight changes of posture may be allowed, and are 
exceedingly grateful to the patient and lessen very much 
the fatigue and irksomeness of the convalescence. The 
limbs may be slowly and gently flexed, and if desired 
may be supported by a large firm roll placed beneath the 
knees. With permission from the physician, the patient 
may be very gently turned upon one side. Pillows or a 
blanket rolled lengthwise should be placed beneath the 
patient to support the body in the new position. The 
head may be slightly raised by shifting the pillow, while 
the pelvis is sometimes raised to promote absorption. 
This is usually done immediately after the operation, 
folded blankets or sheets being placed beneath the pelvis, 
so that the lower portion of the body is considerably 
higher than the upper. After many operations it is 
thought of great advantage to raise the patient's shoulders 
to promote drainage from the abdomen. Patients must 
not be raised too high, as they will often complain of 
faintness, giddiness, and sometimes of disturbed vision. 

THE CARE OF THE SKIN. 

Not only is the patient's comfort greatly promoted 
during convalescence by attention to the skin, but her 
recovery is also hastened. In ordinary cases a soap-and- 
water sponge should be given in the morning, with an 
alcohol-and-water sponge and light rubbing at night. 
The nurse must be careful not to disturb the dressing 
and to move the patient as little as possible in giving 
these baths. When severe shock and depression are 



THE CARE OF THE DRAINAGE-TUBE. l^'J 

present it is advantageous to act constantly upon the 
skin, and the patient may be placed between blankets 
for this purpose. Should septic infection be present, the 
patient may be frequently sponged to reduce temperature 
or to stimulate the blood-vessels. In prolonged cases, 
in which the patient's nutrition is greatly reduced, bed- 
sores may develop. To prevent this complication, bath- 
ing the affected part with alcohol, protecting the tis- 
sues from pressure upon a threatening point, placing 
the patient upon a blanket instead of upon a sheet, the 
use of astringent lotions and powders, may all be tried. 
Unless the patient's position can be so changed that 
pressure is removed, the danger of bed-sores in debilitated 
persons is very considerable. The use of a water- or air- 
bed may be necessary in some of these cases. 

THE CARE OF THE DRA1NAQE=TUBE. 

In some cases a drainage-tube may be left in the lower 
end of the abdominal incision for removal several days 
after the operation. Its care and its removal are usually 
the work of the operator or his assistant. In some 
cases nurses are asked to pump out the drainage-tube at 
frequent intervals for the first twenty -four or thirty-six 
hours after the operation. In these patients a glass tube 



Fig. 87.— Glass drainage-tube (Ashton). 

is employed, which is surrounded upon the abdominal 
surface by sheet rubber. Over the mouth of the tube is 
placed aseptic gauze, and the rubber is folded together 
over the gauze. Thus the remainder of the abdominal 
incision is protected from contamination with the dis- 



358 AFTER THE OPERATION. 

charges from the tube. To empty such a tube the nurse 
requires a piston-syringe, holding several ounces, with a 
long nozzle or having attached to it a piece of sterile 
rubber drainage-tubing. Having made the syringe and 
tubing and her hands aseptic, the nurse unfolds the sheet 
rubber, removes the saturated gauze, introduces the 
tubing and syringe into the glass tube, and, slipping it 
gently down to near the bottom of the tube, withdraws 
the piston of the syringe. The syringe is then with- 
drawn and its contents expelled into a cup or bottle, and 
retained for the physician's examination. When no more 
fluid follows the use of the syringe the internal surface 
of the sheet rubber is thoroughly cleansed with sterile 
water or with an antiseptic solution, a fresh mass of anti- 
septic or aseptic gauze is placed over the tube, the rubber 
is brought together, and the abdominal bandage is re- 
placed. When gauze drainage is employed the nurse 
may be instructed to renew the gauze placed upon the 
surface of the abdomen, but on no account must she 
make traction upon the gauze packing within the abdo- 
men. Strict cleanliness with antiseptic precautions must 
be exercised in this manipulation. 

WHEN IS A PATIENT CONVALESCENT AFTER AB- 
DOMINAL SECTION? 

When the bowels have moved freely, the abdomen is 
soft, painless, and not distended, the temperature not 
above ioo° F., the pulse not above lOO, the kidneys act 
freely, the tongue is moist and clean, and the patient is 
hungry and sleeps without medicine, she is considered 
convalescent. She must still receive exact and faithful 
care before the first dangers following the operation have 
been passed. 



THE NURSE, 359 

THE NURSE. 

A nurse who cares for a case of abdominal section should 
be relieved sufficiently often to enable her to procure 
needed sleep. If possible, two nurses should divide the 
care of such a patient. It must be her effort to surround the 
patient with a gentle, steady, and hopeful influence which 
is of the greatest service. In dealing with such patients the 
nurse will learn to pay little attention to minor com- 
plaints, and to divert the attention of the patient if pos- 
sible from them. She must not forget to keep herself 
well nourished during the strain to which she is subjected. 
Many nurses when losing sleep do not enjoy considerable 
quantities of soHd food. They must then feed them- 
selves with Hquid food at shorter intervals. A nurse can 
usually obtain milk, cocoa, and very often broths and 
soups. Such food, with bread and butter and fruit, serves 
admirably in these emergencies. As soon as possible 
the nurse should be relieved for some portion of the 
time during the day. The early afternoon is a conveni- 
ent time, when the nurse may bathe, and obtain sleep 
and fresh air. If two nurses are employed, they should 
so divide the time that each obtains abundant rest. If 
the physician comes at a regular time to pay his visit, 
both nurses should endeavor to be present. The follow- 
ing information should be given in the record kept by the 
nurse : The pulse, the temperature, and the respiratory 
rate ; the occurrence of vomiting or retching ; the number 
of hours of sleep which the patient obtains ; the quantity 
of urine obtained by catheter or passed spontaneously, a 
specimen being saved for examination; the passage of 
gas from the bowel or from the mouth, and the occur- 
rence of a bowel movement ; the presence of abdominal 



360 AFTER THE OPERATION, 

distention or abdominal pain ; the administration of medi- 
cine ; enemas given and changes of posture made ; medi- 
cines given by hypodermic injection and sponge baths 
administered ; the occurrence of sweating or a dry con- 
dition of the skin ; the presence of delirium, syncope, 
or coma. There should also be noted accurately the 
quantity of food or fluid taken by the mouth, by the 
bowel, by transfusion, or by hypodermoclysis. 



CHAPTER X. 

CONVALESCENCE AND RECOVERY. 

At the conclusion of the operation it is customary to 
place upon the abdomen a dressing composed of aseptic 
or antiseptic cotton enclosed in aseptic or antiseptic 
gauze; wood-wool or jute is sometimes used instead of 
cotton. Such a dressing is retained in position by strips 
of adhesive plaster, which are applied to the sides of the 
body, passing across the dressing and holding it firmly 
in position. Some surgeons prefer to use adhesive strips 
which do not cover the dressing, but which are applied 
at the sides of the body and terminate with stout tapes, 
which are sewed upon the ends of the adhesive strips. 
These tapes are tied across the dressing, thus retaining it 
in position. A many-tailed bandage of flannel is usually 
applied over the strips, and is made by taking a piece of 
flannel wide enough to extend from the buttocks to the 
ribs and nicking it with scissors at points three inches 
apart. This is placed beneath the patient, and the flannel 
is torn in strips at the points nicked, which are then 
passed firmly across the abdomen, overlapping and pinned 
with safety-pins. In some cases drainage is inserted, and 
the dressing is varied in accordance w4th the needs of 
such a case. Should the dressing become stained by 
discharges from the abdomen, the nurse should notify 
the physician at once. Should the dressing become dis- 
placed he must also be informed. Should distention of 
the abdomen become so extreme as to cause great suffer- 

361 



362 CONVALESCENCE AND RECOVERY. 

ing through the pressure of the dressing, the physician 
must be summoned. 

RE=DRESSING. 

In cases in which the dressing does not become soiled, 
and the patient does well, it is sometimes allowed to re- 
main for ten days or two weeks. Other operators prefer 
to change the dressing within the first three days after 
operation. The staining of the dressing by the discharge 
is an indication for renewing it. The nurse should pre- 
pare for this a fresh dressing of cotton and gauze, fresh 
adhesive plaster with or without tapes as desired, and a 
new and clean flannel bandage. Sterile towels will also 
be needed, with sterile water, mercuric chlorid, and gauze 
sponges. The soiled dressing may be dropped into a 
basin or upon a large newspaper, in which it can be 
folded and burned. The physician's hands must be made 
aseptic, and also those of the nurse. The patient is pre- 
pared for the change of dressing by having the limbs well 
flexed and a support placed beneath the knees. The 
dressing is exposed and the clothing and bedding about 
the abdomen are covered w^th clean or sterile towels. 
Materials needed are placed conveniently for the physi- 
cian. The bandage is then opened, the soiled dressing 
removed, and if there has been no discharge a fresh 
dressing is applied. Some physicians powder the ab- 
dominal incision with iodoform and boric acid. If 
discharge is present, the physician will cleanse the 
surface of the abdomen with the gauze sponges and 
sterile water or antiseptic solution. Unless the adhesive 
strips have become much soiled, it is not necessar>^ to 
remove them if the dressing is done soon after the 
operation. While the dressing is being changed, if the 



THE REMOVAL OF THE STITCHES. 363 

nurse finds the skin in the vicinity of the dressing blood- 
stained or soiled, she should take the opportunity to 
cleanse it. If there are points of redness or soreness, 
the application of alcohol will prove useful. When the 
first dressing has been applied the patient must be lifted 
gently a short distance from the bed, the old flannel 
bandage removed and the new one inserted. The strips 
are then applied and the bandage is fastened, beginning 
from above and going downward. In this way steady 
and firm pressure is made upon the abdomen. In hos- 
pitals, dressing-stands are very useful for ward-work in 
these cases. Such can be wheeled to the bedside con- 
taining the materials needed for the renew^al of the dress- 
ing. In private houses such conveniences are lacking. 

THE REMOVAL OF THE STITCHES. 

Many operators remove all or the greater portion of 
the stitches at about the tenth day after operation. Some 
prefer to leave them longer. Some remove a portion of 
the stitches as early as the seventh or eighth day, leaving 
the remainder until the tenth. The nurse should pre- 
pare for this dressings and solutions, as already described 
for changing the dressing. The physician will bring 
scissors, forceps, and any other instrument required, and 
these the nurse should steriHze by boiling. They should 
be placed in a basin or pan of sterile water or antiseptic 
solution. It is best for the patient not to know the 
exact number of stitches, nor to look at them while 
being removed. Thus the ordeal will be less than she 
imagines. If the patient asks if the removal of stitches 
will hurt, the nurse should say that it will, but that the 
pain will not be great, and that the patient will be more 
comfortable afterward. It is never wise to deceive a 



364 CONVALESCENCE AND RECOVERY. 

patient no matter what that patient's condition may be, 
and this is certainly a case in which there is no excuse 
for even a small deception. The nurse should save the 
stitches for the physician's examination, unless she is 
sure that he does not care to examine them. 

STITCH=HOLE ABSCESS. 

As it is almost impossible thoroughly to disinfect the 
skin, it is not surprising to find abscess occasionally 
occurring along the tract of sutures. If promptly treated, 
this is rarely a dangerous complication. Its presence 
may be inferred when the patient has a temperature of 
101° or 102° F., and complains that the stitches are 
painful or irritable. The physician will then change the 
dressing, removing the stitches when suppuration is pres- 
ent and washing out the suppurating tract with sterile 
water or an antiseptic. Hydrogen peroxid is very com- 
monly used for this purpose. A small glass piston- syringe 
is employed, and the antiseptic injected to the bottom of 
the suppurating tract. Such treatment should be given 
daily until suppuration entirely ceases. Stitch-hole abscess 
may not be the fault of the operator or nurse. A patient 
will occasionally pass her fingers or some object beneath 
the binder to rub or scratch the stitches, and thus infect 
them. In a case under the writer's observation a young 
girl infected the stitches after a Cesarean operation by 
passing a hairpin beneath the dressing. She was unwill- 
ing to leave the hospital because outside the hospital she 
was obliged to work. 

When stitch-hole abscess occurs and a discharge 
persists a suture or hgature may be infected. In some 
cases this will loosen and make its way toward the sur- 
face of the body. In other cases it may be removed by 



CHANGES IN DIET— SITTING UP. 365 

making traction upon it with small forceps. In some 
cases the patient must be anesthetized, the sinus dilated, 
and the stitch removed. Nurses should preserve and 
show the physician any knots or bits of suture which 
may stick to the dressing or come out with the dis- 
charges. 

CHANGES IN DIET. 

As the patient advances in her recovery she naturally 
craves solid food. Soft eggs, swxetbread, junket, milk- 
toast, and white meat of chicken and oyster livers are 
the articles of food usually first allowed. Later she may 
take what is known as the light diet of hospital dietaries, 
being careful to avoid all indigestible and heavy articles 
or those which might cause irritation of the intestine. 
Patience and self-denial in the matter of diet will bring to 
the patient an ample reward. Occasionally indiscretion 
in diet has brought about a fatal complication. 

SITTING UP. 

The first sitting up which the patient does should be 
the gradual raising of the shoulders in bed to take food. 
A head-rest may be used for this purpose. Then under 
the physician's orders the patient may be transferred to 
a couch, and very gradually allowed to put the feet upon 
the floor, and finally to bear her weight upon them. It 
is usually very grateful to the patient to be allowed to sit 
up long enough to use a commode. Here again self- 
denial brings abundant reward in the end, as the patient 
by getting up too soon may bring about a hernia of the 
abdominal wall, from which she may be very slow in 
recovering. Much depends upon the vigor of the patient 
and the absence of complications as regards her sitting 
up. Some patients are not out of bed or with the feet 



366 CONVALESCENCE AND RECOVERY. 

upon the floor for four weeks after the operation. Others 
are allowed to get up in three weeks, and each case must 
be governed by the individual conditions. 

VENTRAL HERNIA. 

The abdominal wall is composed of several layers, 
each of different tissue. These are all severed by the 
physician in operating ; and if the abdominal wall is to be 
again as firm and elastic as it was before, these layers 
must be healed together in essentially their original 
arrangement. When this does not occur, as the pa- 
tient gets up and pressure is brought to bear upon the 
scar the tissues gradually separate, leaving only one or 
two layers held together. These are not sufficient to 
hold back the intestine and omentum, and a protru- 
sion occurs formed by the layer covering the intestine 
and the omentum or intestine within. This is termed a 
" ventral hernia," and is an annoying complication in the 
patient's recovery. It is detected by observing a protru- 
sion with a gradual thinning and widening at some point 
in the abdominal scar. It is usually treated by having a 
pad fitted to an abdominal belt in such a position that 
when the belt is applied the pad will make firm pressure 
over the greater part of the entire incision. If the pad 
is too small, it will enter the weakened point and dilate 
the tissues still further, making the hernia larger. Where 
this condition comes on some time after the operation the 
patient must be fitted with a silk and rubber or silk or 
flannel band adapted especially to the purpose. Such 
are usually furnished by those who manufacture deformity 
and orthopedic apparatus. 

The operator will caution each patient to wear a sup- 
porting bandage for a short time after the operation. In 



SUDDEX DEATH DURIXG RECOVERY. 367 

some cases this bandage is worn from six months to a 
year ; in others but two or three months. Such band- 
ages are annoying, because they sometimes chafe and 
irritate the skin, and they have a constant tendency to 
shp above the place where they are needed. This is 
overcome by attaching perineal straps to them, which 
pass over the perineum and are attached to the anterior 
and posterior edges of the bandage. These straps give 
considerable discomfort, however, and may become 
soiled and very irritating. While the patient is wearing 
such a bandage she must take especial care of the skin 
beneath it. Bathing with alcohol and water, or with a 
solution of alum (a teaspoonful to the pint), the use of a 
simple toilet powder, or of powdered boric acid or pow- 
dered zinc oxid, beneath the bandage may be useful and 
tend to lessen its irritation. The patient, however, will 
be but too glad to get rid of all forms of supporting and 
retentive apparatus. 

SUDDEN DEATH DURING RECOVERY FROM ABDOM= 
INAL OPERATION. 

It occasionally happens that upon assuming the sitting 
or erect posture, and sometimes without apparent cause, 
the patient suddenly grows faint and dies. Death comes 
so quickly that little or nothing can be done to prevent 
it. Hypodermic injections of ether given over the heart, 
or of ammonia, the inhalation of stimulating vapor, such 
as that of camphor or alcohol, or amyl nitrite, an effort 
to introduce stimulants into the circulation, placing the 
patient with the head low, are all measures that may be 
used, but generally without the slightest effect. Before 
the nurse can realize the gravity of the situation the 
patient is dead. The cause of this destruction of life is 



368 CONVALESCENCE AND RECOVERY. 

found in a clot which originally formed in the tissue 
about the seat of operation, and which became loosened 
and has been carried in the blood to the heart or brain. A 
nurse should never describe so dreadful an accident to a 
patient. But the knowledge that such may occur should 
make the nurse careful in allowing the patient to exert 
herself during her convalescence. 



CHAPTER XI. 

VAGINAL CELIOTOMY. 

By vaginal celiotomy we understand the opening of 
the peritoneal cavity from below, through the vagina. 
In a number of cases this is an excellent method for 
removing small tumors and for treating inflammatory 
conditions of the pelvic organs. In this operation the 
vagina is opened behind the womb, an examination 
made, and then further opening of the vagina is practised 
until the diseased tissues can be brought down and 
removed in part or entirely. 

Preparations for Vaginal Celiotomy. — The 
preparations for this operation are the same as those 
described in treating of abdominal celiotomy. Especial 
attention must be given to cleansing the pubic region, 
the vulva, the rectum, and the vagina. It is usual to 
scrub the mucous membrane of the vagina with green 
soap and water, douching it copiously with sterile hot 
water, then with mercuric chlorid (i : 2000) or with lysol 
(i per cent.). Especial care is exercised in catheterizing 
the patient and in preparing the rectum before the opera- 
tion. 

Posture. — The patient is placed in the dorsal position, 
and the limbs raised, flexed, and supported by stirrups 
or held by assistants. It must be remembered that in 
any case requiring vaginal celiotomy it may become 
necessary during the operation to place the patient in 
the Trendelenburg posture and open the abdomen. Ac« 
24 , 369 



370 VAGINAL CELIOTOMY. 

cordingly, the patient and the table must be prepared for 
abdominal section and the Trendelenburg posture. 

Instruments and Appliances. — In addition to the 
instruments usually employed for abdominal section, re- 
tractors or specula especially designed for vaginal oper- 
ations are often used. Sutures, ligatures, and needles are 
prepared as usual ; aseptic gauze in strips four inches 
wide and a yard long must be in readiness, while many 
operators prefer iodoform gauze (lo per cent.) of the 
same size. There should be prepared a large vulvar 
dressing composed of bichlorid gauze and sterile or anti- 
septic cotton made into a suitable pad, to be held in place 
by a T-bandage. 

Hemorrhage and Shock. — In many of these oper- 
ations shock is less than in abdominal section. In some, 
hemorrhage is more apt to occur, and the nurse should 
be careful to watch the patient for this complication, not- 
ing the pulse and general condition, and also examining 
the vulvar dressings to detect staining with blood. In 
some of these cases hemostatic forceps wrapped with 
gauze are left within the vagina for some time. If they 
should become separated, serious bleeding may result. 

After-treatment. — It is often necessary to catheter- 
ize these patients for a considerable time after the oper- 
ation. The bowels are moved more easily as a rule than 
after abdominal section, and in the same manner. The 
nurse must be especially careful to cleanse the external 
parts thoroughly with sterile water, then with bichlorid 
solution (i : 2000), and apply antiseptic dressings after 
each emptying of the bowel and bladder. The same 
precautions observed after a case of labor must be car- 
ried out in these patients. 

Dressings. — The physician will usually remove in- 



CONVALESCENCE, 3 7 1 

struments left within the vagina and the first gauze dress- 
ing within a few days after the operation. In some cases 
a veiy gentle irrigation of the vagina with normal salt 
solution is practised. In others the cavity is cleansed 
with gauze sponges dipped in sterile water and the gauze 
packing is removed. Later in the convalescence, should 
a discharge persist, antiseptic or aseptic douches may be 
ordered. 

Convalescence. — In selected cases patients recover 
more easily and rapidly than after abdominal incision. 
In other cases considerable discharge of an unpleasant 
odor persists for some time. While the patient avoids 
the danger of ventral hernia which is present after ab- 
dominal incision, yet the persistent discharge and odor 
are sometimes very annoying. After these operations 
the shoulders and head of the patient should be gradually 
raised in bed to promote free drainage. 



CHAPTER XII. 

CANCER. 

Malignant disease often attacks the pelvic organs or 
the breasts of women. Its high rate of mortaHty, the 
fact that only operations of considerable severity can 
influence the disease, and the pain and distressing symp- 
toms which accompany it make it a terror to patients. 
For this reason friends and relatives often endeavor to 
keep the patient in ignorance of the true nature of her 
malady. The nurse must frequently cooperate with 
them in the attempt. 

Suspicious Symptoms. — While there can be no 
objection to sparing the patient the distress and alarm 
which the knowledge that she has cancer may occasion, 
still the results obtained by early operation are such that 
suspicious symptoms should lead the patient at once to 
consult a physician and to submit promptly to treatment. 
In mammary cancer the presence of a lump near the 
nipple, the drawing in of the nipple, and vague shooting 
pains through the breast are sufficient to require thor- 
ough examination and treatment. 

CANCER OF THE PELVIC ORGANS. 

In cancer of the pelvic organs the occurrence of irreg- 
ular hemorrhage, no matter at what period of life, de- 
mands the most thorough and painstaking examination. 
Cancer is sometimes overlooked if occurring at the meno- 
pause, because the patient believes that irregular hemor- 

372 



CANCER OF THE PELVIC ORGANS. 373 

rhage is due to the cessation of menstruation, and not to 
a foreign growth. Especial caution should be observed 
at this time that the patient may be sure that no serious 
disorder is present. If the patient has a discharge of 
blood, dark, thin, and grumous, offensive in odor, and 
mingled with small particles of grayish or yellow sub- 
stance, this discharge is still more indicative of a possible 
cancer. If the patient describes to a nurse the occur- 
rence of irregular hemorrhage with or without offensive 
discharge, the nurse should urge her by all means to 
seek competent medical aid at once. In such a case 
there may be present some condition which can be com- 
pletely cured without a serious operation. With other 
patients, so soon as the diagnosis of cancer is made the 
uterus must be removed, or the mammary gland. 

Operative Treatment of Cancer of the Pelvic 
and Abdominal Organs. — There is but one treatment 
for this condition, and that is thorough removal by 
surgical means. Numberless other remedies in the way 
of medicines, salves, plasters, douches, cauterizing, and 
electricity have been tried with uniform failure. Opera- 
tion is undertaken in these cases through the vagina 
or through the abdominal wall, and in many instances 
both the abdominal wall and the vagina are opened. 

The preparation for this operation and the care of the 
patient afterward are those already described. In some 
cases, in addition to the removal of the growth by 
cutting instruments, the cautery is extensively employed. 
It may be necessary for the nurse to assist in keeping the 
cautery hot, and she should exercise caution not to burn 
the patient's body or herself with the instrument. Can- 
cer of the womb, if subjected to early operation, is some- 
times delayed indefinitely and occasionally cured. Patients 
often make a speedy recovery from the operation, and 



374 CANCEk, 

live In comparative comfort for an indefinite time. Can- 
cer of the abdominal organs offers a less favorable pros- 
pect, but may sometimes be greatly delayed by early 
operation. 

CANCER OF THE BREAST. 

No treatment but that by operation offers any prospect 
of success in these cases. Careful surgeons are not con- 
tent with removing simply the affected breast, but carry 
the incision into the axilla, removing lymphatic glands 
connected with the breast and any other affected tissue. 
The operation is an extensive one, but in good hands has 
a low rate of mortality. 

Preparation of Patient. — The patient is prepared 
for this operation by purgation, rest in bed, bathing, and 
attention to the condition of the bronchial tubes and kid- 
neys. The axilla on the affected side should be shaved, 
and the skin over the breasts to the axilla thoroughly 
scrubbed with green soap and water, then with alcohol, 
and then with mercuric chlorid (i : looo). A copious 
dressing of bichlorid gauze should be placed over the 
part, filling the axilla completely. At the time of opera- 
tion it is well to put upon the patient a sterile linen jacket 
which will cover completely the anterior surface of the 
body and both arms. This may be made of unbleached 
musHn or other cheap material, and at the time of 
operation the surgeon or nurse may cut away enough to 
expose the parts to be operated upon, leaving the body 
covered with the remainder. The forearm on the affected 
side should be bandaged with sterile gauze, as it will be 
grasped by an assistant to hold the parts in position for 
the operator. 

Preparation of Apparatus.— These operations usu- 



CAXCER OF THE BREAST. 375 

ally require the dorsal position, with limbs extended, 
although the table should be so arranged that the 
patient's head can be lowered if desired. The patient is 
placed at the side of the table, the arm on the affected 
side bandaged on a rest or held by an assistant. As 
many vessels may require ligature, the nurse must see to 
it that an abundance of medium-sized catgut ligatures 
and also an abundant supply of hemostatic forceps are 
in readiness. The operator should select his instruments, 
and should tell the nurse whether he intends to use 
drainage by tubing, by horsehair, by gauze, or by strands 
of silkworm-gut, or any other method. The solutions 
usually employed at major operations should be at hand, 
with appliances for transfusion and resuscitation. Hypo- 
dermic syringes should also be in readiness with other 
appliances for operation. 

The Dressing. — The dressing for such a case is a 
large one, covering the axilla and the side of the chest 
on which the operation occurs. It is retained in place 
by a broad gauze or flannel bandage applied across the 
body and over the shoulders in a figure of 8, or it may 
be kept in place by a bandage resembling the breast 
bandage used after confinement. Gauze and cotton are 
usually employed for the dressing. Wood-wool and jute 
are sometimes used. 

After-treatment. — The patient will need restraint 
until fully recovered from the ether, after which she is 
usually comparatively quiet. If pain be distressing, the 
nurse must summon the physician or give such medicines 
as he may have ordered. She must watch the dressing 
for signs of oozing, and note the patient's pulse and 
general condition to determine the existence of hemor- 
rhage. Many surgeons renew the dressing at the end 



376 CANCER. 

of thirty-six or forty-eight hours, and do not dress the 
wound again until the stitches are removed. If drainage 
has been employed, the means of drainage is usually 
removed at the first dressing. The patient's diet is at 
first liquid, and then increased so soon as the bowels 
have moved, and she is soon put upon light diet. Her 
general care consists in attention to the bowels and skin, 
thorough neatness about her bed and bedding, and atten- 
tion to her nourishment and sleep. The arm may be 
supported in a sling if the operation is not extensive, and 
a large bandage is not required. Such patients are 
usually convalescent in ten days after the operation, or 
occasionally before. As the patient is usually aseptic, 
there should be very Httle variation of temperature after 
the operation, and the patient should make a speedy 
recovery. 

NON=OPERATIVE TREATMENT OF CANCER. 

Unfortunately, many patients delay interference until it 
is hopeless or do not have a correct diagnosis of the case 
made in time for operation. In these cases the condition 
is a very distressing one. Ulceration of the tissue is 
occurring, the patient is annoyed by foul discharges, 
emaciation and weakness are present, pain may be con- 
stant, and the patient realizes that she is in the grasp of 
a fatal malady. While the physician may prescribe 
soothing drugs and comfort by his sympathy, he sees 
the patient but a short time at each visit, and her care 
devolves upon her nurse and friends. 

Keeping the Patient Clean. — The greatest service 
which the nurse can render is to keep the patient clean, 
neutralizing the foul odor of offensive discharges. When 
the discharge comes through the vagina, douching with 



CANCER OF THE BLADDER OR BOWEL. 377 

or without the appHcation of antiseptic powder or anti- 
septic gauze is necessary. While nothing will destroy 
completely the foul odor of advanced cancer, still much 
can be done to mitigate this distress. Douches of potas- 
sium permanganate (the solution being of a mahogany 
color), of creolin (i or 2 per cent.), of mercuric chlorid 
(i : 2000), and of pyoktanin (i : 500) have all been used. 
Antiseptic powders may be thrown into the vagina, such 
as iodoform, iodol, or its derivatives, boric acid, or alum. 
Where bleeding occurs it may be necessary to pack the 
vagina with iodoform gauze. A large vulvar dressing 
of bichlorid or sterile gauze, containing oakum or jute 
or cotton- or wood-wool, must also be used. If irrita- 
tion and chafing result from the dressing, carbolized 
ointments may be employed to advantage. These dress- 
ings must be changed as often as necessary and burned. 
The parts must be thoroughly cleansed externally at 
each changing of the dressing. Glass douche-tubes 
should be employed, and should be kept in an anti- 
septic solution. It is well for the nurse to protect her 
hands with rubber gloves before dressing or douching 
cases of cancer. 

CANCER OF THE BLADDER OR BOWEL. 

When cancer attacks the bladder or bowel it may be 
possible to give the patients a chance for life by opera- 
tion. In cancer of the bowel the cancerous portion 
may be removed, the healthy part being sewn to- 
gether, and thus the canal of the bowel re-established. 
In some cases where cancer is in the lower part of the 
bowel, the abdomen is opened, the bowel severed, and 
the healthy extremity brought up to the surface of the 
abdomen and stitched into the lower end of the incision. 
This makes an artificial anus through which fecal matter 



37^ CANCER. 

is discharged. The patient is thus relieved from the pain 
and distress caused by the passage of feces through 
the cancerous lower bowel. These patients require 
careful nursing, as dressings must be constantly worn to 
receive the fecal matter which oozes from the opening, 
and these dressings must be frequently changed, before 
they become offensive. The skin around the opening of 
the bowel must be kept scrupulously clean, frequently 
bathed with antiseptic solutions, and the skin sometimes 
powdered with boracic acid or baked starch. 

Cancer of the bowel is among the most distressing of 
diseases, frequently causing great pain. Patients have 
foul discharges from the intestine in these cases which 
make it difficult to keep them neat and clean. Their 
constant complaint of pain is often relieved by the for- 
mation of the artificial anus and by the use of opium. 

In cancer of the bladder it may be necessary to open 
the bladder above the pubic bone or from below, in order 
to establish a constant drainage. The bladder is often 
frequently douched with antiseptic solutions, and this is 
entrusted to the nurse. The urine often decomposes and 
becomes very offensivCo Specimens of urine are often 
collected for examination. 

In these distressing cases it may be necessary to use 
the vesical catheter or rectal tube for emptying the bowel. 
The bladder may be douched, or it may be necessary to 
wash out the intestine. Sooner or later in the case come 
involuntary discharges from these organs, which add to 
the patient's distress. The nurse must be especially care- 
ful to keep catheters and tubes thoroughly clean and 
aseptic. Where copious discharges occur, oakum covered 
with several layers of gauze makes excellent absorbent 
material. It should be used abundantly and burned 
promptly when soiled. 



BED-SORES— PAIN. 379 



BED=SORES. 

Patients dying of cancer are especially liable to the 
formation of bed-sores. This sometimes arises where 
the discharges from the vagina or bowel are not properly 
absorbed, but soil the patient's back and are retained 
upon the skin. The patient must not lie upon a bed 
which is soft and yielding, and which does not permit 
the free drainage of discharges. Inflated rubber rings 
or rings made of bandaged oakum may be used to re- 
lieve pressure. Strict cleanliness and the faithful observ- 
ance of all means to preserve the skin must be practised 

in these cases. 

PAIN. 

When active treatment is found hopeless and the dis- 
ease is progressing steadily, pain is usually a prominent 
and distressing symptom. This is often worse at night, 
and does not permit the patient to sleep. There is no 
drug which takes the place of opium in these conditions. 
Morphin, codein, or heroin is usually employed. In 
some cases deodorized tincture of opium by the mouth 
and occasionally opium by rectal suppository are admin- 
istered. If hypodermic medication is practised, the nurse 
must be very careful about the care of the syringe and 
the solutions employed, and with the patient's skin. The 
site of the injection should be antisepticized by soap and 
water, alcohol, and bichlorid solution. Water which has 
been thoroughly boiled should be employed to dissolve 
the morphin. The hypodermic syringe should be fre- 
quently boiled ; or if it is not so made as to permit this, 
the needle should be boiled in soda and water, and the 
barrel of the syringe rinsed in alcohol and hot boiled 
water. The nurse's hands should be thoroughly clean 



380 CANCER. 

when hypodermic injections are given. If care be ex- 
ercised, the patient should not have added to her other 
misery that of abscess following injection. In some 
cases it is possible to remove with the cautery painful 
tissue, thus temporarily relieving the patient. While this 
relief is but slight, patients often desire and request it. 

With many patients pain is much lessened by the free 
use of alcohol. In view of the distressing nature of the 
disease and its hopelessness, it is certainly more merciful 
to allow the patient to use opium and alcohol freely than 
to withhold them because in other cases they do harm. 
The best quality of whiskey is chosen for this purpose, 
and will usually agree best and longest with the patient. 

DEATH FROM CANCER. 

Death comes to these patients by the development of 
cancer of the internal organs, or by gradual failure of 
strength and blood-poisoning from absorption of the 
necrotic tissue of the cancer. All that can be done is to 
keep the patient free from pain and as clean as possible. 
Death usually occurs with symptoms of exhaustion, 
coma, and heart-failure. Physicians and friends usually 
feel that it is not right to prolong the suffering of such 
patients by the administration of powerful stimulants to 
maintain life. 

DANGERS OF INFECTION. 

The nurse must remember that cases of cancer are in 
a high degree septic. She must accordingly protect her- 
self from septic infection, and take measures to disinfect 
thoroughly articles used about the patient and her room. 
Clothing that has been worn by a cancer patient should 
be burned. The same is true of bedding, of matting or 
carpets in the room, and of utensils used about her. The 



DANGERS TO THE NURSE. 38 1 

room and its contents should be thoroughly fumigated 
with formaldehyd. If the bed be of iron, it should be 
scrubbed with green soap and water, with hot water, and 
then with an antiseptic solution. Paper should be removed 
from the walls and the room repapered or painted. No 
case of confinement should occur in a room occupied by 
a cancer patient for some time after the case of cancer 
has been ended. No surgical operation should be under- 
taken in this apartment. 

Dangers to the Nurse. — The nurse should take 
especial precaution that her hands are free from wounded 
surfaces while caring for a cancer case. Rubber gloves 
should be employed while dressing the patient and han- 
dling soiled dressings. We have no practical proof that 
the nurse may become infected by cancer through caring 
for such a case. Before the nurse takes another case 
she should disinfect her body as thoroughly as possible, 
washing the hair thoroughly ; and should change her 
clothing completely, using clothing which has not been 
worn with the cancer case. If she can afford to do so, 
she should destroy the dresses and aprons which she has 
worn at the case. If she cannot afford this, they should 
be repeatedly boiled before being used again. Nurses 
who have taken care of cancer cases should not take 
obstetric or surgical cases for several months afterward. 
They should acquaint the physician in charge w^ith the 
fact, and tell him what precautions they have taken to 
make themselves aseptic. He will then share with them 
the responsibility of the case, and should complications 
be unjustly blamed upon the nurse the physician can 
protect her. 



CHAPTER XIII. 

MENTAL DISEASES COMPLICATING PELVIC 
DISORDERS. 

It is not infrequent to find among women suffering 
from pelvic disease a considerable number of mental dis- 
orders as well. Of these, the most frequent is melancholia. 

MELANCHOLIA. 

These patients are depressed and unhappy, imagining 
that they have lost the affection of those about them, 
and are the victims of groundless fears, suspicions, and 
misapprehensions. They take little or no interest in 
things about them, are indifferent in their nutrition, and 
very difficult to affect by any form of treatment. The 
tendency to suicide develops among them, and requires 
the closest attention on the part of the nurse or attend- 
ant. Such patients are sometimes very favorably in- 
fluenced by operative treatment. The anesthesia makes 
a total break in the monotony of their feelings, while the 
operation interrupts for the time being the chain of mor- 
bid symptoms from which they have suffered. In such 
a patient the nurse should take care always to present a 
hopeful view of the situation, while she must be on her 
guard for any tendency toward suicide. 

PERVERSIONS. 

In some cases of pelvic disease the patient's natural 
modesty of feeling is greatly altered or entirely lost. At 

382 



MAiVIA — GENERAL CARE. 383 

the menstrual period the patient grows much worse in 
behavior, is greatly excited, and requires close attention. 
Many of these cases are improved by operative treat- 
ment, while others are hopeless. The nurse in charge 
of such a patient must keep her thoroughly and surgi- 
cally clean, thus removing as far as possible sources of 
irritation to the pelvic organs. Constipation must be 
avoided, bathing, exercise, and outdoor life encouraged, 
and the patient's nutrition promoted in every possible 

way. 

MANIA. 

Disease of the pelvic organs does not cause active 
insanity, but may be present in insane patients and in- 
crease their excitability and suffering. If a nurse is 
placed in charge of one of these patients for operation, 
she must remember never to trust the patient alone. It 
is sometimes necessary to restrain such patients, tying 
them in bed to prevent them from undoing the results 
obtained from operation while the wound is healing. 
They should be kept as quiet as their condition permits, 
and often make good recoveries from operations. In 
some cases it is difficult to dress them, and they some- 
times disturb the dressing. This requires close watchful- 
ness on the part of the nurse, the use of anodynes, and 
very carefully applied and very firmly bandaged dressings. 

GENERAL CARE. 

In cases of mental disease complicated by disorders 
of the pelvic organs the nurse should decline to express 
an opinion regarding the probability of cure by opera- 
tive treatment. This question is so difficult to decide 
that she should not take the responsibility. She should 
urge, however, that all patients be subjected to a thor- 



384 MENTAL DISEASES AND PELVIC DISORDERS. 

ough examination by a competent physician, and that 
this examination should take place while the patient is 
under the influence of an anesthetic. 

THE MENOPAUSE. 

The cessation of menstruation is often accompanied or 
followed by considerable disturbance in the functions of 
the nervous system. Flashes of heat or cold, giddiness, 
ringing in the ears, eruptions upon the skin, excessive 
sweating, flushing of the face, derangements of the blad- 
der and rectum, may all be present. When the meno- 
pause is brought about artificially by the removal of the 
ovaries the same symptoms occur, often with greater 
violence and with a peculiar effect upon the mind. Some 
patients are greatly relieved and improved in health 
by the artificial cessation of menstruation. Their 
strength increases, appetite improves, they are com- 
paratively free from pain and distress, and take a new^ 
interest in life. Others, however — and this is the larger 
class — feel that they are different from other women and 
brood over the disease which has made this necessar)% 
becoming melancholy or very eccentric. 

The nursing of such a case requires great patience and 
tact, with the steady application of those means w^hich 
tend to reestablish the circulation and relieve the patient's 
distress. Massage, baths, outdoor life, gentle exercise, 
are all most valuable. The bowels must move daily and 
properly, and the skin must receive attention. The 
patient should take an abundance of gentle exercise in 
the open air ; and if this is not possible the muscles must 
be moved by the electric current, this treatment being 
combined with massage. So far as the mental treatment 
of the condition goes, the effort must be made to interest 



THE MENOPAUSE. 385 

the patient in other things than herself and her symp- 
toms. Too much attention must not be paid to the 
various sensations which she describes. The cheerful 
and hopeful view must be taken of the situation, and the 
patient encouraged to believe that she will before long be 
relieved of her distressing symptoms. 

25 



CHAPTER XIV. 

VENEREAL OR SPECIFIC DISEASE. 

Nurses must not be surprised to find cases of venereal 
or specific disease in any class of patients. In many 
of these cases the patient is entirely innocent so far as 
the acquiring of the disease is concerned. She is also 
ignorant of the nature of her malady, and has not taken 
alarm early, but very probably has allowed the disease 
to progress until it has become fully established. 

GONORRHEA. 

The symptoms of this disorder are a yellowish or 
grayish discharge from the urethra and vagina, burning 
and smarting pain on urination, with redness and swell- 
ing about the entrance to the vagina. The discharge is 
often irritating, and an eruption upon the skin may occur 
about the vulva and anus. If the disease is not checked 
and the patient does not take rest, pain in the lower por- 
tion of the abdomen shows that inflammation is spread- 
ing throughout the pelvis. Ultimately inflammation of 
the peritoneum with or without the formation of abscess 
may result. 

The ^Effects of Gonorrhea. — Gonorrhea resembles 
a slow fire creeping through underbrush. While com- 
paratively not severe at first, the infective germ travels 
steadily through the various channels of the pelvis, until 
the lining membrane of the womb and of the Fallopian 
tubes and the peritoneal covering of these organs, with 



GONORRHEA. 387 

the connective tissue of the pelvis, become involved. The 
lining membrane of the bladder may also be infected, and 
the infection may travel up the ureters and abscess form 
in the kidneys. If the e}xs become infected from the 
discharge, severe inflammation and blindness may result. 
Should the infection enter the general circulation blood- 
poisoning and death may follow. Sterility is not an un- 
common result of gonorrhea, while inflammation and 
adhesions of the tubes and uterus are very common. 

The Conveyance of Gonorrhea. — The gonorrheal 
discharge is distinctly contagious and infectious. Hence 
children may acquire the disease from sleeping with an 
adult who has such a discharge, or by the use of towels 
or bedding stained with it. Dirty catheters, douche- 
tubes, syringes, or other appliances may convey the 
infection. The hands and fingers frequently carry it. 

Treatment. — The nurse must remember that each 
case of gonorrhea is a thoroughly septic case. Strict 
antiseptic precautions in the use of solutions and dress- 
ings must be observed. The treatment usually consists 
of vaginal douches of antiseptics, with the application of 
iodoform or other antiseptic substances to the tissues 
about the entrance to the vagina. The physician may 
make applications to the vagina or neck of the womb 
with instruments. The discharge must be received upon 
antiseptic gauze or other suitable dressing, and these 
dressings should be burned as soon as soiled. The 
patient's bedding and all appliances used about her must 
be considered septic, and disinfected accordingly. The 
medicinal treatment of this disorder consists in limiting 
the diet, giving the patient very freely water to drink, 
and moving the bowels veiy thoroughly. Confinement 
to bed is practised during the active stage of the first 



388 VENEREAL OR SPECIFIC DISEASE. 

inflammation, with the use of the ice-bag over the abdo- 
men and thorough disinfection of the vagina to prevent 
abdominal inflammation. When such a patient is up and 
about she may be annoyed by a whitish or grayish-white 
discharge, which is also infectious. She should wear a 
dressing and take strict precautions until she is abso- 
lutely without discharge of any sort. 

Care of the Nurse. — The nurse who treats a case 
of gonorrhea should use rubber gloves in giving douches 
and making dressings, and must be especially careful to 
keep her hands away from her face and eyes. The hands 
should be thoroughly cleansed and disinfected before the 
face is washed, and the eyes must not be rubbed with the 
fingers. Carelessness may result in infection of the eyes, 
followed by bhndness. The nurse must consider herself 
septic with regard to cases of confinement or surgical 
operations. She should take neither without disinfection 
of her body and clothing, and with full knowledge and 
consent of the physician in charge. 

SYPHILIS. 

Acute syphilis is characterized by a sore or ulcer upon 
the vagina or cervix ; by a rose-red or dark-red eruption, 
becoming copper-colored ; by a sore throat with patches 
of swelling and redness upon the mucous membrane ; by 
headache and loss of hair ; and by the development of 
disease of the bones, liver, and nervous system. It may 
be transmitted to offspring, and syphilitic children are 
ill-nourished, pale in color, often deformed, and of feeble 
vitality. 

Treatment. — The physician will usually make appli- 
cations to a syphilitic ulcer to destroy the poison in 
the part. The nurse may be required to give vaginal 



SYPHILIS. 389 

douches, to use antiseptic dressings, and keep the patient 
clean. Medical treatment is used extensively in syphilis, 
and mercury and potassium iodid are given in large 
doses. Where extensive ulceration is present the ulcers 
must be dressed with antiseptics and protected by suit- 
able dressings and bandages. All soiled dressings must 
be carefully burned, and the patient treated as a surgi- 
cally septic case. The nurse must be cautioned that the 
disease may be conveyed by the discharges in the acute 
stage, and that a raw or wounded surface upon the 
fingers is the most usual place of inoculation. Syphilitic 
patients should not use the same cups, glasses, or table 
articles used by others. If the patient has syphilitic 
sores in the mouth, there is danger of contamination in 
this way. The nurse must take especial caution in the 
care of her hands, and in the avoidance of all risks of 
contamination. 

The Results of Syphilis. — While a certain number 
of cases of syphilis are cured by vigorous treatment, in 
many recovery never occurs. Disease of the bones or 
blood-vessels gradually develops, the liver and internal 
organs are affected, and death ensues not as the direct 
result of syphilis, but caused by the changes which 
syphilis brings about. 

The Treatment of Hereditary Syphilis.— The 
treatment and nursing of syphilis in the newborn child 
have been described in the section upon Obstetrics. 
Older children may have syphilitic ulceration upon vari- 
ous parts of the body, especially about the mouth and 
nose, ulcers upon the scalp, or ulcers upon the legs and 
about the anus and vulva. These cases must be treated 
as distinctly septic, and every precaution taken to avoid 
contamination of other parts of the body, and also to 



390 VENEREAL OR SPECIFIC DISEASE. 

secure the proper absorption and destruction of syphilitic 
discharges. Tonic treatment, careful feeding, cod-liver 
oil, and the best possible hygiene are used in these cases. 
Precautions for Nurses in Dealing with these 
Cases. — In addition to the risks of physical contamina- 
tion, other responsibilities are placed upon the nurse with 
these patients. With married women who have been 
infected by their husbands the occurrence of such infec- 
tion might be made the occasion of divorce. While no 
one can deny the justness of this, still the knowledge of 
the patient's malady should not come to her through the 
nurse. She should remain strictly non-committal upon 
the nature of the disease, referring the patient and her 
friends to the physician for information. If this be true 
regarding a patient, the nurse must be still more silent in 
giving information to anyone else regarding the patient's 
disease. Scandal is so easily excited that, if the nurse 
were to describe the patient's symptoms to others, a sus- 
picion of specific disease and rumors of such a condition 
might readily be excited. Accordingly the nurse must 
guard very strongly the secret which has come without 
any wish of hers into her possession. In justice to 
others, she must remember that upon leaving such a 
case she is practically septic, and she must be exceed- 
ingly thorough and careful in disinfection before taking 
an obstetric or surgical case. 



APPENDIX. 

DIETARY. 

Albumin or White -of- egg Water. — Stir whites 
of two eggs into one-half pint of ice water without beat- 
ing. Add enough salt or sugar to make palatable. 

Barley-water, Gruel or Jelly. — Wash two ounces 
of pearl barley with cold water= Boil five minutes in 
fresh water; throw both waters away. Pour on two 
quarts of boiling water ; boil down to a quart. Strain 
(if patient desires) and flavor with thinly cut lemon rind. 
Add sugar to taste. 

To make jelly, put two tablespoonfuls of washed pearl 
barley into a saucepan with one and one-half pints of 
water. Boil slowly down to a pint. Strain and allow 
liquid to set into a jelly. 

Beef-juice. — Cut a thin juicy steak into pieces one 
and one-half inches square, and brown separately one 
and one-half minutes in a frying pan. Squeeze in a hot 
meat-squeezer or lemon-squeezer, and flavor with salt and 
pepper. May serve hot or cold. 

Beef Sandwich (Scraped). — Scrape pulp from a 
good steak, season to taste, and spread thinly on thin 
slices of buttered (slightly) bread. 

Beef- tea. — One pound of steak from top of round; 

one pint of cold water; salt. Wipe steak, remove all 

fat, and cut in small pieces. Soak three hours in the cold 

water ; then place on back of range for one hour, care 

^ 39X 



392 APPENDIX. 

being taken that the heat is not sufficient to coagulate the 
juices. Strain, season, and re-heat; same care as re- 
gards juices in heating as before. 

Chicken-broth. — Dress and clean a chicken. Re- 
move skin and fat, disjoint, and wipe with a wet cloth. 
Put into kettle with one and one-half quarts of cold 
water ; heat to boiling-point, skim, and cook slowly until 
meat is tender. When half done add one and one-half 
teaspoonfuls of salt and a few grains of pepper. Cool 
thoroughly and skim fat. Re-heat and serve. 

Clam-broth. — Wash thoroughly six large clams in 
shell ; put in kettle with one cup of water ; bring to boil 
and keep there one minute ; the shells open, the water 
takes up the proper quantity of juice, and the broth is 
ready to pour off and serve hot. 

Mutton-broth. — Add one pound of loin of mutton 
to three pints of cold water ; boil slowly until very 
tender, adding one teaspoonful of salt when half done. 
Strain, and when cold skim off fat. Three tablespoon- 
fuls of rice or the same amount of barley added makes 
it more palatable. The following formula for mutton- 
broth has been found especially useful : Three pounds of 
loin of mutton are placed in three quarts of water. The 
meat is slowly boiled until it becomes very tender, adding 
a little salt. To this add one pint of stewed or canned 
tomatoes, and one cup of rice. Boil for half an hour, 
strain through a very fine sieve, remove the fat by skim- 
ming, and serve hot. 

Oyster-broth. — To one dozen oysters with liquor 
add one cup of cold water. Let it come to a boil and 
boil for five minutes. Strain and season. 

Veal-broth. — Mince one-half to one pound of lean 
veal ; pour over it a pint of cold water. Let it stand for 
three hours ; then slowly heat to boiling-point. After 



DIETARY. 393 

boiling briskly for two minutes strain through a fine sieve 
and season with salt. 

Buttermilk. — Buttermilk should be prepared from 
good, pure cream by churning process. After the butter 
is formed, the milk should be strained and kept well 
covered in a cool place. 

Com Gruel. — Two tablespoonfuls of Indian meal ; one 
tablespoonful of flour ; one-half teaspoonful of salt ; three 
cups of boiling water. Mix the meal, flour, and salt. 
Add enough cold water to make a thin paste. Add to 
boiling water and boil gently one hour. Dilute with 
milk or cream. 

A richer gruel may be made by using milk instead of 
water, and cooking three hours in double boiler. 

^gg and I/emon. — Beat one ^^^ with one table- 
spoonful of sugar until very Hght. Add three table- 
spoonfuls of cold water, and juice of small lemon. Fill 
glass with pounded ice and drink through a straw. 

^Z% and Milk. — Beat milk with salt to taste. Beat 
white of ^^^ until stiff, and add ^g'g and milk and stir. 

]$gg-nog with Stimulant. — Make mixture same as 
for plain egg-nog, and pour it over one tablespoonful of 
wine or brandy diluted with same quantity. Shake well 
and serve at once. 

I^gg-nog without Stimulant. — Beat an ^g^ slightly 
and add one teaspoonful of sugar and a few grains of 
salt. To this add one glass of milk. Mix thoroughly 
and strain. A slight grating of nutmeg if desired. 

l^nemata (Nutrient) Containing Milk. — Peptonize 
the milk by the warm process, then add whatever other 
ingredients the physician may order. 

Flaxseed Tea. — Remove black specks from two 
tablespoonfuls of whole flaxseed. Add to it one heap- 
ing tablespoonful of whife sugar and a little lemon-juice. 



394 APPENDIX. 

Pour on these materials two pints of boiling water. Let 
stand in hot place four hours. Strain and serve either 
hot or cold. 

Hominy Jelly. — One-half cup of fine hominy added 
to one quart of boiling water and one-half teaspoonful of 
salt. Cook in double boiler down to one pint. Time, 
three hours usually. 

Junket. — One cup of milk, one tablespoonful of sugar, 
one tablespoonful of sherry wine, one teaspoonful of liquid 
rennet. Heat milk until lukewarm ; add sugar and wine ; 
when sugar is dissolved add rennet. Turn into a small 
mould and let stand in cool place until firm. Serve with 
sugar and cream. For flavoring, cinnamon or nutmeg 
may be used in place of wine. 

Koumiss. — One quart of milk; one and one-half 
tablespoonfuls of sugar; one-third yeast cake dissolved 
in one tablespoonful of lukewarm water. Take ordinary 
beer bottle with shifting cork. Heat milk until luke- 
warm ; add sugar and dissolved yeast cake. Fill bottles 
within one and one-half inches of top ; cork and invert. 
Let stand for six hours at a temperature of 80° F. 
Place on ice and use after twelve hours. Much waste 
can be saved by preparing the bottles with ordinary 
corks wired in position and drawing off the koumiss 
with a champagne tap. 

Milk, Peptonized. — Cold Process. — In a clean quart 
bottle put one peptonizing powder (extract of pancreas, 
five grains ; sodium bicarbonate fifteen grains) or the 
contents of one peptonizing tube (Fairchild). Add one 
teacup of cold water, shake ; add one pint of fresh cold 
milk and shake mixture again. Pack bottle in ice and 
use when required without subjecting to heat. 

Warm Process. — Mix peptonizing powder with water 
and milk as described above ; place bottle in water so hot 



DIETARY. 395 

that the entire hand can be held in it for a minute with- 
out discomfort. Keep bottle there ten minutes ; then 
pack in ice. 

Milk Punch. — One cup of milk ; one teaspoonful of 
sugar ; one tablespoonful of brandy ; a few grains of salt. 
Dilute brandy with w^ater (one tablespoonful), add sugar 
and salt, then milk. Shake thoroughly. Serve at once. 

Oatmeal- water, Gruel, or Jelly.— One cup of fine 
oatmeal ; tw^o quarts of water (which has been boiled 
and cooledj. Add oatmeal to water and keep in a warm 
place (at a temperature of 80° F.) one and one-half hours. 
Strain and cool. 

GrucL — One-half cup of coarse oatmeal ; three cups 
of boiling water ; one teaspoonful of salt. Add oatmeal 
and salt to boiling water and cook in double boiler three 
hours. Force through a strainer and dilute with milk 
or cream. Reheat and season. 

Rice-water, Gruel, or Jelly. — ^Pick over and wash 
two tablespoonfuls of rice. Add to it two cups of cold 
water and boil until rice is soft. Strain and add milk or 
cream if desired. Reheat and season with salt. 

Prepare gruel or jelly as pearl barley. 

Toast- water. — Equal measures of stale bread toasted 
and boiling water. Cut bread in inch sHces, put in pan, 
and dry thoroughly in a slow oven until crisp and browii. 
Break in pieces, add water, and let stand one hour. Strain 
through cheesecloth and season. Serve hot or cold. 

Wheat- water, Gruel, or Jelly. — Using the entire 
w^heat, prepare the same as barley-water. 

Gruel. — One tablespoonful of flour ; two cups of milk ; 
pinch of salt. Mix flour with one-fourth cup of milk. 
Scald remaining milk in double boiler, add flour paste, 
and cook thirty minutes. Season. 



396 APPENDIX. 

PREPARATION OF SURGICAL SUPPLIES. 

Sterilisation. — By Dry Heat. — Instruments, dress- 
ings, and appliances may be made sterile by dry heat. 
Thorough baking has long been known to be an efficient 
method of bringing about this result. In the absence of 
appliances for boiling or steaming, this may be resorted 
to in private houses as a means of sterilization. It is 
difficult to estimate the precise temperature employed, as 
a thermometer can scarcely be used with a range or cook 
stove. This method cannot be a very accurate one, and 
is inferior to boiling or steaming. If baking is employed, 
at least one-half hour should be devoted to this method 
of sterilization. The material to be sterilized should be 
placed in a perfectly clean pan and put into an oven. It 
is well to leave the door of the oven slightly ajar, that 
the smell of burning may be quickly detected. 

Boiling is a method of sterilization well adapted to the 
preparation of instruments. At 212° F. germs may be 
destroyed without injury to the object sterilized. Metal 
objects are best boiled in a i per cent, solution of sodium 
carbonate, which prevents rust. Rubber appliances can- 
not be boiled without softening hard rubber and destroy- 
ing its shape. Soft-rubber articles can be boiled, but no 
alkaKne substance should be added to the water. To be 
thorough, sterilization by boiling should occupy one-half 
hour. Should this be impossible, at least ten minutes 
must be devoted to the boiling of instruments. 

Steaming. — Sterilization by steam is preferred for the 
preparation of gauze, sheets, towels, blankets, gowns, 
caps, and all fabrics. The penetrating power of steam 
enables us to sterilize thoroughly the meshes and threads 
of cloth, which cannot be done so well in any other way. 



PREPARATION OF SURGICAL SUPPLIES. 



397 



Steam sterilizers vary greatly in complexity, size, and 
cost. The best are those which bring steam to bear 
under pressure, thus forcing the heated vapor through 
the articles to be sterilized. It is possible by this means 
to place an object in a glass tube, plugging the tube with 
cotton, and placing the tube in a steam sterilizer, to have 
the steam forced through the cotton and thus sterilize 
the contents of the tube. 

By Formaldehyd. — The vapor of formaldehyd is an 
efficient sterilizing medium. Its cost and irritating prop- 




. — Apparatus for use in sterilization by means of formaldehyd. 



erties make it less available than steam under pressure. 
Instruments may be sterilized by formaldehyd by placing 
them in a suitable chest or box in which the vapor is 
formed and from which the air is carefully excluded. 
The accompanying illustration shows Reik's sterilizer 
(Fig. 88) for the use of formaldehyd. Fifteen minutes' 
time is necessary for such sterilization. Tablets of for- 



398 APPENDIX. 

maldehyd are heated by an alcohol lamp, thus liberating 
the antiseptic vapor. 

The Preparation of Dressings. — Operators in 
hospitals differ considerably in the preparation of sur- 
gical dressings. This arises from various views regard- 
ing the efficiency of different methods, and also from the 
fact that there is a wide difference in the sorts of steril- 
izers and apparatus possessed by various hospitals. The 
writer gives methods which have proved satisfactory, and 
adds to them those employed in several reliable hospitals 
where a number of operators are constantly at work. 

Cheesecloth Gauze. — A very efficient dressing is made 
from a cheap quaHty of cheesecloth. This should first 
be boiled in a i per cent, solution of sodium carbonate 
or bicarbonate until the material placed in the cloth 
by the makers to facilitate its folding and packing has 
been thoroughly removed. The cheesecloth should be 
carefully rinsed and dried, and may then be cut into 
convenient sizes. If it is desired to make a sterile dress- 
ing only, pieces of this cloth should be sterilized by 
steam three times, for one-half hour at each time. If it 
is desired to make the cheesecloth antiseptic, it should 
be soaked in mercuric chlorid solution (i : looo), to 
which salt is added to prevent decomposition of the 
bichlorid. It may then be kept in sterile jars tightly 
closed. If gauze be purchased, it is well to cut it into 
convenient lengths and to resterilize it, keeping always on 
hand a supply sufficient for any emergency, and resteril- 
izing frequently so that the gauze may be thoroughly 
reliable. 

Bichlorid Gauze. — Cut gauze in one-yard pieces ; boil 
for twenty minutes. Soak in i : 2000 bichlorid for twenty- 
four hours. Wring out, fold in sterilized sheets, and dry. 



PKEPARATION OF SURGICAL SUPPLIES. 399 

Take off outside sheet and sterilize gauze for one hour. 
Fold in four-inch wide pieces, roll, and keep in sterile jar. 

Iodoform Gauze. — In hospitals iodoform gauze is pre- 
pared by the nursing staff and kept constantly on hand. 
In practice conducted in private houses it is convenient 
to employ iodoform gauze furnished by reliable manufac- 
turers, and put in small, tightly sealed glass jars. Such 
jars must not be opened until the gauze is needed ; and 
if the entire contents of a jar are not used, the remainder 
should be thrown away or very carefully sterilized by 
steam or boiling before it is again employed. 

Preparation of Iodoform Gauze. — Cut five pounds of 
gauze in two-yard pieces, boil for twenty minutes, wring 
out, and soak in bichlorid i : 2000 for twenty -four hours. 
Wring out in sterile pan. Make an emulsion of one-half 
pound of iodoform that has been sterilized and \\ pints 
of sterile glycerin. Add this as needed to \\ pints of 
alcohol. Dip the gauze in the alcohol to which the 
emulsion has been added, wring out, and rub gauze until 
the color is even. Fold in four-inch wide pieces and roll. 
Place in sterilized covered jar and keep in dark closet. 

Washing and Re -sterilisation of Gauije and 
Bandages. — The expense of gauze is so great that ex- 
periments have been made to determine whether the 
outer layers of dressings which do not become stained 
with discharges, might not safely be washed and re-steril- 
ized for further use. This has been found feasible, and 
the following method is that employed at the Pennsyl- 
vania Hospital : 

All gauze and bandages from all dressings are collected 
in paper bags and taken to the laundry. There they are 
transferred to netted cord bags, which are only half filled. 



400 



APPENDIX. 



These are put to soak over night in cold water, which is 
changed several times. The following day they are 
placed in an iron washer capable of resisting steam pres- 
sure up to ten pounds. They are then washed in cold 
water until it runs perfectly clear. The gauze, still in 
these bags, is then washed with warm water, soap, and 
sal soda, and rinsed in hot water. After the rinsing, 
enough hot water is turned into the washer to cover the 
bags of gauze. Steam is then turned on to a pressure 
of ten pounds, the thermometer showing a temperature 
of 236° F. This temperature is maintained for one-half 
hour. During all this process the washer is moving with 
a to-and-fro motion, which continually agitates the gauze, 
and presents all parts of it to the action of the water and 
steam. The bags containing the gauze are then put in the 
extractor, and are then returned to the hospital, where 
they are overhauled under the direction of the Supervisor 
of Nurses. The gauze is untangled, straightened, cut, 
placed in packages, and sterilized. The final sterilization 
is done at a temperature of 250° F., with a pressure of 
fifteen pounds. 

If gauze is to be washed, the best quality must be 
selected. A separate plant is required, costing several 
hundred dollars, but this is more than saved from the 
amount spent for new gauze. In the operating-rooms 
new gauze only is employed. Repeated tests show that 
the old gauze, treated by this method, is absolutely 
sterile. 

Cotton. — Cotton must be sterilized by baking, and its 
inflammable character must be remembered and caution 
taken to avoid burning. The difficulty of sterilizing 
cotton has limited its use to filling dressing composed 
largely of gauze. The gauze thus comes next to the skin 
of the patient, as it may be made thoroughly antiseptic. 



PREPARATION OF SURGICAL SUPPLIES. 40.I 

Sheets, Towels, Blajikets, Caps, and Gozvns. — Such 
material is best sterilized by steaming under pressure, 
and this should be done when possible in a separate 
sterilizer from that employed for the preparation of liga- 
tures or dressings. It is best to employ such a sterilizer 
that after steam has been used sufficiently long it may be 
turned off, and hot air forced through the fabrics, drying 
them thoroughly. They may then be folded or rolled 
carefully with sterile hands, and pinned up in bundles in 
sterile linen and labelled. 

Bandages. — Bandage material which is thoroughly 
clean is considered satisfactory by most operators. If, 
however, sterile bandages are desired, they may be made 
of gauze rolled upon a small stick to give firmness, steril- 
ized, and wrapped in sterile materials in small bundles. 
The many-tailed flannel bandages used after abdominal 
section do not require to be steriHzed, as they do not 
come in contact with the immediate vicinity of the wound. 

Preparation of Adhesive Strips. — These are of two 
kinds, those which pass entirely across the surface of the 
abdomen, and those to which tapes are attacked, which 
are tied over the dressing. The first may be cut at the 
time when the dressing is made, as the plaster will keep 
moist better in the roll than after the strips are cut ; or 
the strips may be cut previously and kept in a jar or air- 
tight tin can. If tapes are used, the length of the ad- 
hesive portion of the band should not be less than six 
inches, and the tapes should be sewed to the adhesive 
plaster firmly. 

Preparation and Care of Instruments. — Instruments 
may be prepared for operation by boiling them for twenty 
minutes in i per cent, solution of sodium carbonate. 
This is conveniently done in covered trays, which need 

26 



402 APPENDIX. 

•not be opened until just at the beginning of the opera- 
tion. The use of the soda prevents rusting, and 
cleanses the instruments by dissolving any albuminoid 
material which may adhere to them. Some operators 
prefer to have instruments boiled and then placed, after 
rinsing in a solution of carbolic acid (i per cent.) or in 
sterile water. We have had the best results by boiling 
instruments in lysol solution (one per cent.). This pre- 
vents rust, is antiseptic, and does not injure the plating. 
We have had good results from the use of covered trays, 
which require no further manipulation of the instruments. 
If the operation has been upon a septic case, the instru- 
ments should be immediately sterilized after its comple- 
tion. They should be boiled at least one-half hour after 
such a case. If the case has been aseptic, the instruments 
should be washed with hot soap and water, and brushed 
with a nail brush or jewelers' brush, especial attention 
being paid to joints, locks, and corrugated surfaces, the 
instruments being taken apart for such cleansing. The 
instruments may then be dried, and the joints lubricated 
with sterile glycerin or sterile olive oil. They should 
be placed upon a glass shelf in an air-tight cabinet or 
case. Instruments may be scoured with any simple 
cleansing powder, and should be promptly replated if 
the plating breaks and rust begins to appear. It should 
be the duty of the nurse or assistant in charge of instru- 
ments to see that they are kept sharp and in proper con- 
dition. 

Needles. — Damaged needles should be at once de- 
stroyed. To keep them from rusting, needles may be 
kept in alcohol or in glycerin. Some prefer to stick them 
into a mass of carded wool kept in a small case with a 
screw top. This prevents rusting and is a convenient 
method for retaining them. 



PREPARATION OF SURGICAL SUPPLIES. 403 

Sutures. — Silkworm-gut is most readily sterilized, 
and is the most reliable suture material in use. It may 
be prepared by boiling, by soaking in mercuric-chlorid 
solution I : 1000), or by boiling in a glass tube contain- 
ing alcohol, after which the tube is closed with a tight 
cork. Silkworm-gut is sometimes purposely softened 
and made antiseptic by boihng it in creolin or lysol. A 
simple and convenient method of preparing it is to boil it 
with the instruments. Care should be taken to select 
the best gut ; and it may be purchased in quantities from 
dealers in fishermen's supplies, and the best and longest 
strands chosen. 

Silk. — The best quality only of silk must be selected. 
Fine, medium, and large silk are the sizes used. What 
is known as " pedicle silk " is most employed for ligating 
important vessels in the pelvis and the pedicles of tumors. 
Silk should be wound upon glass reels, and may be pre- 
pared for operation by boiling for one-half hour several 
times. It may be sterilized by steam, by wrapping the 
reels in gauze, stitching the bundle together, and not 
opening the gauze until the time of operation. Although 
silk is weakened by long-continued and repeated boiling, 
still the best silk is uninjured by several sterilizings. 
Fine silk should not be repeatedly boiled. The nurse 
should endeavor to estimate how much will be required 
for an operation, and this should be freshly prepared 
just before the operation. It may be kept in glass tubes 
plugged with cotton, in which it has been sterihzed, or in 
alcohol. 

Catgut. — Numerous methods for the preparation of 
catgut are followed by various hospitals and operators. 
For work in private houses, catgut put up in hermetically 
sealed tubes by reliable makers is very convenient and 



404 APPENDIX. 

has proved reliable. The tube is placed in the sterilizer 
with the instruments and silkworm-gut, and is again 
sterilized by boiling. At the time of operation the tube 
is grasped in the hands wrapped in a towel, and is 
broken at a mark filed upon the glass. The catgut 
wound upon a glass rod or reel is then dipped in sterile 
water if the gut is too stiff for the convenience of the 
operator, when it will usually be found ready for use. 
Catgut must be kept in alcohol or bichlorid solution or 
in carefully closed receptacles. 

Marine Sponges.— Marine sponges are difficult to 
prepare, and have been largely replaced by gauze pads 
and sponges. The following method is that given by 
Kelly: i. Lay them in a stout cloth and pound suffi- 
ciently to break up grit and lime. 2. Rinse with warm 
water ten or more times until it remains clear. 3. Im- 
merse in a muriatic-acid solution (two drams to one 
pint) for twenty-four hours. 4. Immerse in saturated 
warm potassium-permanganate solution. 5. Decolorize 
in a hot oxalic-acid solution. 6. Pass through lime-water 
to take out all the oxaHc acid. 7. Rinse thoroughly in 
plain sterile water. 8. Immerse in a i : 1000 solution of 
mercuric chlorid for twenty-four hours. 9. Preserve 
until used in a 3 per cent, carbolic-acid solution. The 
hands manipulating the sponges during these prepara- 
tions from step 4 on must be sterile, and much manipu- 
lation may be done with instruments. When wanted for 
use the sponges are lifted out with long sterilized forceps 
and rinsed in sterilized water. 

The following method is given by the Americmt Text- 
book of Stirgejy, page 1 170 : Marine sponges should be 
first placed in a bag and beaten for a long time in order 
to free them from the sand in their meshes. They should 



PREPARATION OF SURGICAL SUPPLIES. 405 

then be washed for some days in water which is frequently 
changed, and best in water which is slightly acidulated 
with hydrochloric acid. They must again be washed in 
pure water in order to remove the acid. Different 
methods may be followed in their disinfection : i. They 
may be soaked for twenty-four hours or less in a solution 
of ordinary washing soda, a pound of the soda to a 
dozen sponges, and the soda then be removed by washing 
in clean water. The sponges are next soaked for twenty- 
four hours in a i : 20 carbolic-acid solution, and dried by 
moderate artificial heat. They are then well wrapped up 
and kept in a dry place. 2. After beating the sponges 
free from sand and washing them in the warm water 
they should be soaked in a solution of potassium per- 
manganate (half an ounce to the gallon), and if the pink 
color of the solution is lost more permanganate should 
be added. If this addition is necessary, the sponges 
should be taken out of the hquid, the permanganate dis- 
solved, and the sponges put back, for if the permanganate 
is put in upon the sponges it discolors them in spots. 
They are then washed in warm water and dipped for a 
very few minutes in a solution of sodium sulphite (ten 
drams) and hydrochloric acid (two ounces to the gal- 
lon of water). If they are allowed to remain any length 
of time in this solution, they will not only become 
bleached, but very much softened. They are then 
thoroughly washed for twenty-four hours, after which 
they are kept in glass jars in a carbolic solution (i : 40), 
3. Borham's method is that adopted by Greig Smith in 
preference to others. The sponges after being cleansed 
are first soaked in a i per cent, solution of potassium 
permanganate (about seventy-five grains to the pint). 
The sponges, having next been washed repeatedly in 



400 APPENDIX. 

boiled water, are placed in a gallon of water in which has 
been dissolved half a pound of sodium hyposulphite for 
a dozen sponges. Four ounces of oxalic acid are added, 
which bleaches the sponges and dissolves out any fibrin 
in their meshes. They should remain in this solution 
not more than ten minutes, and are finally placed in a 
carbolic solution. 

Gloves. — Rubber gloves may be sterilized by boiling 
or by steam, and placed in a bichlorid solution until they 
are used. Some operators prefer to have them dry when 
placed upon the hands, while others fill them with bichlo- 
rid or lysol solution, allowing the antiseptic fluid to escape 
gradually as the hands are inserted, while others use ster- 
ile glycerin as a lubricant. Grease should not be used 
upon rubber gloves. They should be completely turned 
and thoroughly dried after use, and sterile gauze should 
be packed into the fingers and palm to keep the surfaces 
from adhering. 

Disinfection of the Body. — To cleanse thoroughly 
the body of an operator or nurse, the Turkish bath is the 
most available procedure. This may be followed by a 
bath in dilute antiseptic solution ; but usually the Turk- 
ish bath is sufficient. The hair should be thoroughly 
washed and shampooed, and carefully dried. Absolutely 
clean clothing must always be worn. The attention of 
nurses as well as physicians must be called to the fact 
that those persons who have purulent or mucopurulent 
discharges from the body cannot be considered aseptic, 
and should not take part in surgical work. 

Flimigation. — The most efficient and convenient 
method of fumigation and disinfection which has come 
under our observation is that by formaldehyd. The fol- 
lowing method has given us excellent results, as proved 
by bacteriologic examination, at the Jefferson Maternity. 



PREPARATION OF SURGICAL SUPPLIES. 



407 



Formaldehyd lamps as devised and furnished by Scher- 
ing and Glatz have been employed. The larger size has 
been employed for rooms, and the smaller for closets, 
incubators, and cases. These lamps consist essentially 
of an open cup, beneath which is an alcohol lamp. By 
the heat of the lamp the vapor of formaldehyd is lib- 
erated, and accomplishes its purpose by penetrating all 
portions of the room. 

The room which is to be fumigated should have doors 
and windows thoroughly calked with cotton or oakum, 





Fig. 89.— Apparatus for generating formaldehyd from tablets of polymerized for- 
maldehyd : 1, small form ; 2, for larger quantities ; A in each figure indicates the cup 
in which the tablets are placed. 

and paper pasted over the edges of cracks around the 
doors and windows. Cupboards or closets communicat- 
ing with the room must be widely opened ; furniture and 
bedding may be arranged conveniently within the room. 
A large pan is placed upon the floor, and in this several 
inches of water. Two bricks are placed in the center of 
the pan, and on these the formaldehyd lamp. The lamp 
is prepared for use by filling the cup with pastiles of 
formaldehyd, using as many as the cup will hold. The 



408 APPENDIX. 

alcohol lamp is filled, and the wick trimmed. . The pas- 
tiles are then moistened with alcohol and the alcohol 
lamp is lighted. The door is then closed and the room 
allowed to remain unopened for twenty-four hours if 
possible. Should this not be possible, twelve hours at 
least must elapse. 

When the room is opened it must be thoroughly aired, 
as the fumes are very irritating. The paint in the room 
should then be scrubbed, the floor and furniture scrubbed, 
and the walls and ceiling thoroughly wiped. The room 
should remain open to the air for twenty-four hours if 
possible. Fumigation is often done by fumigating cylin- 
ders or small stoves which are placed in a room and 
lighted, the room being then tightly closed. F.ormal- 
dehyd vapor is most efficient, but so irritating to the 
throat and nose that it must be used with great caution. 
Accordingly, the room must be very tightly sealed by 
pasting paper over the cracks and about the doors and 
windows. Pastiles of formaldehyd are very convenient 
for use in fumigation. 

Preparation of Iodoform Gaui^e in Consider- 
able Quantities. — Ten pounds by weight of gauze are 
soaked in a solution of mercuric chlorid (i : looo) for 
twenty-four hours. Iodoform (one pound), glycerin (one 
pint), and alcohol (one pint) are mixed, twenty-two and 
a half grains of mercuric chlorid having been dissolved 
in the alcohol. This is three tablets, each seven and a 
half grains. This iodoform mixture should stand several 
days before using. The gauze is then wrung out of the 
bichlorid solution, cut in two-yard lengths, and put 
through the iodoform emulsion. If this emulsion is not 
a perfect one, add glycerin or alcohol to dissolve thor- 
oughly the different ingredients. The gauze is rolled, 
and is not exposed to light. 



PREPARATION OF SURGICAL SUPPLIES. 409. 

Chromici^ed Catgut.— Catgut may be prepared 
advantageously as follows : Carefully selected gut is 
soaked in Squibb's ether for twenty-four to forty-eight 
hours. The ether is then poured off, and a solution 
composed of mercuric chlorid (forty grains), tartaric 
acid (two hundred grains), and alcohol (twelve ounces), 
is then poured upon the catgut. The gut is allowed to 
remain in this solution for ten minutes to a half hour, 
according to the size and strength of the catgut. Medium 
sizes are left from twenty to twenty-five minutes. This 
bichlorid and alcohol solution is then poured off, and the 
gut is washed well in alcohol. It is then immersed in potas- 
sium bichromate (five grains), water (one-half pint), and 
alcohol (95 per cent.) (one-half pint). This solution must 
be carefully prepared, for if a precipitate forms the solution 
is useless. The catgut is left in this twenty-four hours, 
when the solution is poured off and the gut again thor- 
oughly washed with alcohol. It is then placed for keep- 
ing in the following solution : Alcohol (95 per cent.) 
(one pint) ; solution of palladium chlorid (fifteen grains 
to one ounce) (two drops). Be careful never to touch 
the catgut in changing the solution or in washing. Cat- 
gut not chromicized is prepared in the same manner with 
the omission of the use oi the solution containing potas- 
sium bichromate. Tablets of mercuric chlorid and ammo- 
nium chlorid must not be used in preparing catgut, as the 
ammonium chlorid affects the gut. 

Cumol Catgut. — Catgut is also prepared, by Kronig's 
method, by using cumol. (Kelly's Operative Gy7iccology) 

1. Cut the catgut into the desired lengths and wind 
twelve strands into a figure-of-eight form, so that it may 
be slipped into a large test-tube. 

2. Bring the catgut gradually up to a temperature of 
80° C, and hold it at this point one hour. 



4IO APPENDIX. 

3. Place the catgut in cumol, which must not be above 
a temperature of 100° C. ; raise it to 165° C. and hold it 
as this point for one hour. 

4. Pour off the cumol and either allow the heat of the 
sand-bath to dry the catgut, or transfer it to a hot-air 
oven, at a temperature of 100° C, for two hours. 

5. Transfer the rings with sterile forceps to test-tubes, 
previously sterilized as in the laboratory. 

In making the catgut up into skeins it is only neces- 
sary to tie the ends in the isthmus of the figure of eight 
to hold them securely in proper shape. If convenient, 
it is better to use the hot-air oven for the drying process ; 
but this is not absolutely essential, as a sand-bath can be 
improvised, as suggested by Kronig, to serve this purpose. 
A beaker glass of at least a half liter capacity is em- 
bedded three-fourths of its height in a tin or agate-ware 
vessel of sufficient capacity to permit three-fourths of an 
inch of sand to be packed about the sides and beneath 
the glass. 

In drying or boiling, the catgut should not come in 
contact with the bottom or sides of the vessel, but should 
be suspended on slender wire supports or placed upon 
cotton loosely packed in the bottom. During the drying 
process the beaker glass is covered with a sheet of paste- 
board, through which a centigrade thermometer is thrust, 
so that the mercury bulb may be suspended about mid- 
way in the vessel. In this way the temperature can be 
regulated perfectly. A Bunsen burner is placed under 
the sand-bath, and the temperature in the beaker glass is 
slowly brought up to 80° C, where it is held for one 
hour to dry the catgut. A higher temperature than 
100° C, before the catgut is thoroughly dry, renders it 
brittle ; this step in the method must be carried out most 



PREPARATION OF SURGICAL SUPPLIES. 4I I 

carefully. When the drying process is completed the 
cumol is poured into the beaker glass and brought up to 
a temperature of 165° C, a little short of the boiling- 
point, with two Bunsen burners. A copper-wire netting 
should be placed over the beaker glass to prevent the 
ignition of the cumol. This temperature is more than 
sufficient to kill all micro-organisms, and it is not neces- 
sar}' to allow the cumol to boil, which causes unneces- 
sar}' evaporation. The catgut is left for one hour at 
this temperature, when the cumol is poured off for sub- 
sequent use. 

Cumol, which is of a clear, limpid, or slightly yellow- 
ish appearance when procured from the chemist, is 
changed to a brownish color by boiling. 

The catgut is allowed to remain in the sand-bath until 
the excess of cumol is driven off and it appears entirely 
free from any oily matter. A period of one to two hours 
is usually sufficient to dry it thoroughly. 

From the sand-bath or hot-air oven it is transferred 
with sterile forceps to sterile test-tubes, such as are used 
for culture-media, in which it is preserved from contam- 
ination until ready for use. Small quantities should be 
placed in each tube, to obviate the necessity of opening 
them too frequently. 

In conclusion, it is well to bear in mind that while 
cumol is not explosive it is very inflammable, and great 
care should be observ^ed in lifting the wire screen from 
the beaker glass to prevent drops of the cumol from 
faUing into the flame or on the heated piece of metal on 
which the sand-bath rests, as it will take fire, flare up, 
and ignite the fluid in the beaker glass. Such an acci- 
dent has occurred three times in our experience. 



412 APPENDIX. 

OTHER METHODS FOR THE PREPARATION OF 

SURGICAL SUPPLIES AND ASEPTIC 

PRECAUTIONS. 

Preparation of Catgut.— The following methods 
of preparing catgut have been found reliable : 

Place catgut in ether for forty-eight hours, then boil 
in alcohol for twenty minutes each day for three succes- 
sive days. Heavy gut requires one-half hour. It is then 
ready for use. 

Place catgut in ether for five hours ; then in oil of 
juniper berry for twenty -four hours. Boil ten minutes 
each day in alcohol for three successive days. Keep in 
alcohol. 

Place catgut in formahn (2 per cent.) for twenty-four 
hours ; then place in 95 per cent, alcohol. Dried and 
prepared each time it is needed. 

Place catgut for four hours each day for three succes- 
sive days in benzin. Then boil in 95 per cent, alcohol 
twenty minutes each day for three successive days. 

Place catgut in benzin for twelve hours ; then in oil of 
juniper berry for twelve hours. Boil this for two hours, 
using an Arnold sterilizer. 

Place the gut in benzin for fourteen hours. Then 
wash in sterile water and dry. Now place in formaldehyd 
(5 per cent.) fourteen hours. Wash in sterile water and 
dry for four hours on frame. Wind on spools and place 
in 5 per cent, glycerin in absolute alcohol. (In small 
quantities, take one part of glycerin to 19 parts of abso- 
lute alcohol.) The spools are placed in air-tight tubes 
(metallic) and sterilized for forty-five minutes at 240° F. 



PREPARATION OF SURGICAL SUPPLIES. 413 

To chromicize catgut : 



Ten per cent, carbolic acid, 


2 fl. oz. ; 


Chromic acid, 


I fl. dr.; 


Catgut, 


ildr. 



Allow this to stand for twenty-four hours ; then put 
in alcohol for keeping. 

In getting the correct weight of gut, the following has 
been tested and weighed by a druggist : 

Catgut, size A, 48 strands 24 inches long equals \yi dr. 
Catgut, size B, 45 strands 24 inches long equals ij^ dr. 
Catgut, size C, 42 strands 24 inches long equals I ^ dr. 
Catgut, size D, 25 strands 24 inches long equals i^ dr. 

Sizes B, C, and D are generally used. A is used for 
eye-work. It is much better to have all catgut wound 
on spools, glass preferred. If these are not convenient, 
roll in rings around the finger and fasten loosely. A 
small amount of glycerin added to any of these prepara- 
tions will tend to keep the gut soft, and prevent its curl- 
ing and becoming brittle, as it does where inferior alcohol 
is used. The glycerin should be added just before boil- 
ing. 

Gau^e. — Preparation of Iodoform Gauze. — Soak four 
yards of gauze in bichlorid (i : 500) for twenty-four 
hours. Wring the gauze from the bichlorid and thor- 
oughly saturate with a mixture of alcohol (2 ounces), 
glycerin (2 ounces), and pulverized iodoform (8 drams). 
Rub and slap well into the gauze. Roll or fold, and 
sterilize for ten minutes in an Arnold sterilizer. 

Preparation of Sterile Gauze. — Take four yards of 
gauze ; roll and sterilize in an autoclave thirty minutes 
each day for three days. 



414 APPENDIX. 

Preparation of Bichlorid Gauze. — Plain gauze im- 
mersed in bichlorid solution (i : 500) for thirty-six hours. 
Fold, roll, and sterilize in an autoclave for twenty min- 
utes. 

Preparation of Gau^e Pads for Abdominal 
Operations. — Gauze pads for abdominal operations 
should be of sizes from six inches square to twelve inches 
square. Eight thicknesses of gauze are used in each 
pad. Turn in the edges of the gauze and hem neatly. 
Wrap in towels, one dozen in each package, and sterilize 
in an autoclave. They are again sterilized just before 
using. 

Preparation of Gau^e Strips for Packing. — 
Gauze strips for packing are cut from plain sterile or 
iodoform gauze. Fold the gauze lengthwise, folding first 
in half, then doubling a second and a third time. Now 
turn back the free edge of the gauze, leaving a free edge 
on either side of the strip. They are cut in strips thirty- 
six inches long and width of the gauze, being the length 
of the strip. The width of the strips is from one inch to 
eight inches. Fold in packages (different widths in sepa- 
rate packages), and sterilize the plain gauze in an auto- 
clave and the iodoform in an Arnold sterilizer. 

Incinerating Soiled Material. — There is no satis- 
factory method of destroying material soiled with septic 
discharge, except the use of fire. It is often difficult, 
even in hospitals, to burn a considerable quantity of 
dressings. These are soaked with septic fluids and do 
not readily burn, and would clog a furnace in which they 
might be. put. Various sorts of incinerators have been 
manufactured expressly to dispose of such waste. At 
the Jefferson Maternity very satisfactory service has 
been given by an incinerator whose flame is supplied 



PREPARATION OF SURGICAL SUPPLIES. 



415 



by gas jets (Fig. 90). Soiled dressings are wrapped in 
old paper, placed in the wire basket of the incinerator, 
and the full flame gradually turned on. In a few moments 




Fig. 90. — Gas incinerator for destroying soiled dressings. 

the dressings are reduced to ashes. It is part of each 
nurse's duty on different days to be responsible for the 
incineration of dressings, and the duty is a most responsi- 



4l6 APPENDIX. 

ble one. The incinerator must be placed where it cannot 
cause danger from fire. It must be near a large chimney 
in which the flames and smoke may go. This chimney 
should be one which is kept constantly warm in winter 
by receiving heat from the furnace, or some other fire in 
the cellar. Unless the incinerator stands upon a rock or 
cement floor, zinc should be placed beneath it, and also 
should cover the sides of the wall nearest the incinerator. 

Preparations of Marine Sponges. — Wash in run- 
ning water until soft and clean and entirely free from 
sand. Then place in potassium permanganate (i : looo) 
for ten minutes ; then in hydrochloric acid (lo per cent.) 
for twenty minutes ; then put in oxalic acid for fifteen or 
twenty minutes. Take from the oxalic acid and wash 
thoroughly in cold sterile water until the acid is removed. 
Place in carbolic-acid solution (i : 60) until used. 

Preparation of Steriliijed Silk.— Usually boiled 
in alcohol (95 per cent.) for ten minutes when needed. 
Some doctors prefer silk steam sterilized with dressings 
for one hour. 

Preparation of Silkworm-gut. — Place in bichlo- 
rid solution (i : 1000) for twelve hours; then boil in 95 
per cent, alcohol for fifteen minutes, just before using. 

Preparation of Normal Salt Solution. — To one 
pint of sterile water add forty-five grains or three-fourths 
teaspoonful of sterile salt. Have water warm. 

Preparation and Sterilisation of Instruments. 
— All instruments except cutting instruments are boiled 
in a steam sterilizer for fifteen or twenty minutes. Bis- 
touries or other instruments with sharp edges are wrapped 
in cotton and boiled for three to five minutes, or placed in 
a solution of carbolic acid (i : 20). 

Preparation and Sterilisation of Dressings.— 



PREPARATION OF SURGICAL SUPPLIES. 4 1 7- 

All dressings are wrapped in towels, labelled, and steril- 
ized in an autoclave for thirty minutes. 

Preparation and Sterilisation of Iodoform. — 
Iodoform powder is placed in a sterile glass jar. A piece 
of gauze is fastened securely about the top of the jar. 
The whole is well wrapped in a couple of towels and 
sterilized for one hour in an Arnold sterilizer. 

Preparation and Sterilisation of Boric Acid. — 
Boric-acid powder is prepared and sterilized in the same 
manner as iodoform powder. 

Preparation and Sterilisation of Glycerin. — 
Place the bottle of glycerin wrapped in a towel in an 
autoclave. Keep there for thirty minutes under ten 
pounds pressure. 

Preparation of Adhesive Strips. — Plain adhesive 
strips for abdominal dressing. The plaster is torn from 
the cloth in strips twenty-six inches long and two and 
one-half inches wide, and laid on a piece of oiled silk, 
from which they are easily removed when needed. Straps 
with tapes are made from strips of adhesive plaster six 
inches long and three inches broad. The ends of the 
strip are square. Take both corners of one end of the 
strip and turn them in. This leaves one end pointed and 
covered with the cloth on the back of the plaster. Sew 
firmly pieces of white tape to these pointed ends. Place 
on oiled silk. 

Preparation and Sterilisation of Jars. — All jars 
are washed with soap and water and then with bichlorid 
(i : looo), after which they are covered with towels wrung 
out of bichlorid solution (i : lOOo). 

Preparation and Sterilisation of Irrigators. — 
Fountain and glass syringes are boiled in a steam steril- 
izer for fifteen or twenty minutes, dried and wrapped in 
27 



41 8 APPENDIX. 

towels until needed, when they are placed in carbolic- 
acid solution (i : 40). 

Preparation and Sterili^jation of Tables. — 
Tables are washed with a solution of bichlorid (i : 1000) 
after being cleaned with soap and water. 

Preparation and Sterilisation of Surgeons* 
Gowns. — Surgeons' gowns are wrapped in packages, 
three gowns in each package, and steriHzed in an auto- 
clave. 

Preparation and Sterilisation of Rubber Arti- 
cles. — Rubber articles, such as aprons, pillow-covers, 
etc., are washed with carbolic-acid solution (i : 20). 

Preparation and Sterilisation of Gloves. — Rub- 
ber gloves are thoroughly washed with tincture of green 
soap and sterile water, rinsed with sterile water, and then 
placed in bichlorid (i : 100) for a few minutes. They are 
then put in boiling water for about a minute. This is 
done with sterile hands. Take out of water and lay on 
a sterile towel. When dry, dust with sterile pulverized 
starch, and pack with sterile gauze, five or six layers cut 
in the shape of a hand. Powdered starch is again dusted 
into the glove and on the surgeon's hands before putting 
them on. Cotton gloves are washed, boiled, dried, then 
put in packages, and sterilized in an autoclave for thirty 
minutes. 

Preparation and Sterilisation of the Hands. — 
The hands should be kept as smooth as possible ; nails 
short and well manicured. With a sterile nail-brush the 
hands and arms are thoroughly scrubbed with warm 
sterile water and green soap for five minutes, then rinsed 
with sterile water and immersed in bichlorid (i : 1000) 
for five minutes, again using sterile brush. They are 
then scrubbed thoroughly with benzin or alcohol (95 per 



PREPARATION OF SURGICAL SUPPLIES. 419 

cent.), and rinsed with sterile water. In addition to this, 
some surgeons use potassium permanganate (i : 16) and 
oxaHc acid (10 per cent.). Immersing the hands in lime- 
water after this soothes the irritation. 

Weir's method for rendering the hands soft and smooth 
and making them antiseptic is as follows : Take a tea- 
spoonful of sodium carbonate and one of chlorid of lime. 
Mix in the palm of the hand with water enough to make 
a cream. Rub the hands and arms well, cleansing the 
nails with soft sterile wood sticks (orange-wood pre- 
ferred). Rinse with sterile water. 

Rules for Nurses for Maintaining an Aseptic 
Condition of the Body and Clothing.— Nurses may 
maintain an aseptic condition of body and clothing by 
bathing first with green soap and water, hair included ; 
then with bichlorid (i : 5000). Rinse this off and dry. 
Clean cotton clothes and fresh cap are donned, and over 
all is worn a large sterile apron covering the whole dress. 
No nurse attending obstetric cases should be sent 
directly to maternity wards from a ward where a septic 
condition of wounds exists or where infectious maladies 
exist. When on duty in maternity wards, she should 
not be allowed to enter any other part of the hospital. 



INDEX, 



Abdomen, abscess in, drainage of, 

154 
bandages for, 59 
increase in size of, in normal 

pregnancy, 28 
operation on, preliminary prepa- 
ration of, S33 
Abdominal binder, 59 

distention after gynecologic op- 
erations, 351 
operations, gauze pads for, 414 
sudden death during recovery 

from, 367 
supporting bandage after, 366 
ventral hernia after, 366 
organs, cancer of, operative treat- 
ment of, 373 
section, delivery by, 140. See 
also Cesarean section. 
hemorrhage after, 344 
Abortion, 106 
asepsis ii , 107 
bleeding in, 108 
consetjuences of, 107 
local treatment of, 107 
rest in, 107 
Abscess, breast-, in puerperium, iSi 
drainage of, 154 
stitch-hole, 364 
Absorbent-cotton and cheesecloth 

dressings, 58 
Accidents of labor, 114 
Adhesive strips, preparing, 401, 417 
After-pains, 185 

Air, fresh, in normal pregnancv, 27 
Albumin water, 391 
Amnion, 14 
Amniotic fluid, 14 

discharge of, no, in 
Anatomy of pregnancv, 18 
Anesthesia in obstetric operations, 
126 
by nurse, 127 ■^■ 



Anesthetics in second stage of labor, 

Anesthetizer in gynecologic opera- 
tions, 337 
Anesthetizing-room, 317 
Antiseptic covers for jars and 
tables, 332 
gauze to prevent return of post- 
partum bleeding, 118 
preparations for Cesarean sec- 
tion, 141 
solutions in gynecologic examina- 
tions, 261 
in treating ophthalmia neona- 
torum, 224 
vaginal douches, 283 
Antiseptics for gynecologic opera- 
tions not opening perito- 
neal cavity, 308 
Apparatus, electrical, for operating- 
room, 324 
for generating formaldehyd from 
polymerized formaldehyd 
tablets, 407 
for gynecologic operations, 319 
for washing bladder, 294, 296 
improvised, for operations, 327 
Aprons, bathing-, 102 
Arnold steam sterilizer, 320 
Artificial breathing for child, 121 

feeding of child, 189 
Asepsis during puerperal period, 
87, 90 
j in abortion, 107 
Aseptic precautions, 412 
Asphyxia, 121 
of child, 119 
Astringent vaginal douches, 283 

Baby, blue, 17 
Baby-clothes, 65 
Bandages for abdomen, 59 
for breast, 59 

421 



422 



INDEX. 



Bandages for leg, 109, no 
preparation of, 401 
supporting, after abdominal sec- 
tion, 366 
vulvar, material for, 57 
washing and re-sterilization of, 

399 
Barley-gruel, 391 
Barley-jelly, 391 
Barley-water, 43, 391 
Basins for confinement, 64 

for operating-room, 322 
Bathing in normal pregnancy, 27 
Bathing-aprons, 102 
Baths in diseases of lungs in infan- 
cy, 215 
Bed for confinement, 64 
Bed-sores in cancer cases, 379 

in pernicious nausea, 47 

in puerperal sepsis, 173 
Beef sandwich, scraped, 391 
Beef-broth, preparation of, 44 
Beef -juice, 199, 391 

raw, preparation of, 43 
Beef -tea, 391 

Bending-forward posture, 275 
Bichlorid gauze, preparing, 398, 414 
Binder, abdominal, 59 

box-, 118 

breast-, 89 

in labor, 75 
Birth of child, 54 
Birth-canal, 20 

cleansing of, 170 

disinfection of, 157 
Birthmarks, 230 

Bladder, apparatus for washing, 
294, 296 

cancer of, 377 

douching of, 293 

irritabihty of, in pregnancy, 34 
Blankets, sterilization of, 401 
Bleeding. See Hemorrhage. 
Blue baby, 19 
Body-pack in diseases of lungs in 

infancy, 215 
Boiling method of sterilization, 396 
Boldt's table, 321 
Bony pelvis, 20 
Borham's method for preparation 

of marine sponges, 404 
Boric acid, preparation of, 417 
sterilization of, 417 



Boric-acid douches, 285 
Boroglycerid douche, 285 
Bottles, feeding without, 200 

for feeding, 191 
Bowel, cancer of, 377 

feeding by, in pernicious nausea, 

44 
Bowel-movements in infancy, hab- 
its of, 211 
in puerperium, 85 
Bowels, 80 

first movement of, after gyneco- 
logic operations, 353 
in operations on pelvic floor, 166 
on perineum, 166 
on vagina, 166 
treatment of, before gynecologic 
operations, 313 
Box-binder, 118 
Brain, water on, 235 
Breast-abscess in puerperium, 181 
Breast-binder, 89 
Breast-pump, 99, 179 
Breasts after weaning, 192 
anatomy of, 30 
bandages for, 59 
caked, in puerperium, 177 
cancer of, 374 

care of, during puerperium, 89 
complications with, in puerper- 
ium, 176 
development of, during preg- 
nancy, 22 
distention of, in puerperium, 177 
enlargement of, in infancy, 239 
in normal pregnancy, 30 
Breathing, artificial, for child, 121 
Broths, 392 

preparation of, 43, 44 
Buttermilk, 393 

Caked breasts in puerperium, 177 
Cancer, 372 

bed-sores in, 379 

dangers of infection in, 380 

to nurse in, 381 
of abdominal organs, 373 
of bladder, 377 
of bowel, 377 
of breast, 374 

after-treatment of, 375 
non-operative treatment of, 
376 



423 



Cancer of pelvic organs, 372 

pain in, 379 
Caps, sterilization of, 401 
Capsules, vaginal, 278 
Carbolic-acid douches, 284 
Carded-wool tampons, 278 
Castor-oil mixture for constipation 

in pregnancy, 38 
Catgut, boiling of, 410 

chromicized, preparation of, 409, 

413 
cumol, preparation of, 409 
drying of, 410 

preparation of, 403, 409, 412 
weights of, 413 
Catheter, antiseptic precautions in 

use of, 90 
Catheterization after gynecologic 
operations, 354 
before gynecologic operations, 

335 
in first stage of labor, 67 
Catheterizing in operations on 

womb, 159 
Celiotomy, dangers of, 312 
vaginal, 369 

after-treatment of, 370 
hemorrhage in, 370 
Cervix, disinfection of, for opera- 
tion on womb. 157, 158 
needles, 131 
Cesarean section, 140 
after-care, 146 

antiseptic preparation for, 141 
convalescence from, 147 
duties of nurse before, 145 

during, 145 
preparation of patient for, 141 
preparations for, 142 
vomiting after, 147 
Cheesecloth and absorbent-cotton 
dressings, 58 
gauze, preparation of, 398 
Chicken-broth, 392 
preparation of, 43 
Child, birth of, 54 
clothes for, 65 
constipation in, 202 
crib for, 65 
descent of, in normal pregnancv, 

28 
development of, 245 
diarrhea in, 202 



Child, feeding of, artificial, 189 

mixed, 189 

partial, 189 
indigestion of, 201 
length of, 247 
motion of, 249 
nerves of, care of, 249 
newborn. See Newborn child. 
nursing of, in puerperal sepsis, 

175 
prematurely born, care of, 203 
dressing of, 205 
feeding of, 206 
incubation for, 203 
stim\ilation for, 206 
sight of, 248 
temper of, 250 
weaning of, 192 
weight of, 245 
Chlorid, mercuric, douche of, 283 

poison from, 283 
Chorion, 14 
Chromicized catgut, preparation of, 

4C0, 413 
Circumcision, 229 

hemorrhage in, 229 
Clam-broth, 392 
Cleanliness of mother in puerpe- 

rium, 82 
Cleansing birth-canal in puerperal 
sepsis, 170 
mouth of child, 120 
stitches closing lacerations, 151 
Cleft palate, 233 
Clothes, baby-, 65 
Clothes-basket as incubator, 204 
Clothing for confinement, 64 
for nurse in operations, 338 
for operations in private houses, 

125 
in first stage of labor, 68 
in normal pregnancy, 24 
physician's in gynecologic opera- 
.tions, 337 
Colic, mixtures for, 200 
Colostrum, 96 
Confinement, basins for, 64 
bed for, 64 
clothing for, 64 
dressings for, 57, 62 
ligatures for, 64 
medicines for, 62 
mother's figure after, 93 



424 



INDEX. 



Confinement, room for, 63 

time of, 80 

time of getting up from, 92 
Constipation in child, 202 

in infancy, 209 

in pregnancy, t^^ 
Constitutional disorders of infancy, 

234 
Convalescence from Cesarean sec- 
tion, 147 
from gynecologic operations, 358, 

'361 
from postpartum hemorrhage, 

from vaginal celiotomy, 371 
Convulsions in infancy, 242 
Corn-gruel, 393 _ 
Cotton, sterilization of, 400 
Counter-irritants for diseases of 

lungs in infancy, 215 
Counter-irritation in puerperal sep- 
sis, 170 
Cows' milk, care of, 192 

composition of, 192 

dilution of, 190 
Cracks in nipples, t8o 
Craniotomy, 139 
Creeping, 250 
Creolin douche, 284 
Crib, 65 

Cumol catgut, preparation of, 409 
Curvature of legs, 230 
Cyanosis in infancy, 2'^-^ 

Davis's glass douche-tube, 74 
intra-uterine douche, 155 
method of sterilizing hands, 330 
obstetric forceps, 131 
uterine dressing-forceps, 132 
Death from cancer, 380 

sudden, during recovery from ab- 
dominal operation, 367 
Delivery by abdominal section, 140 
See also Cesarean section. 
by forceps, 130 

duties of nurse in, 134 
instruments for, 130 
preparation of patient for, 133 
Walcher's position in, 135 
feet-and-breech, 78 
of head last. 79 
of placenta, 77 
Dentition, 213, 252 



Descent of child in normal preg- 
nancy, 28 
Development of child, 245 
Diarrhea in child, 202 

in normal pregnancy, 34 
Diet after labor, 86 

after operative treatment of 

breast-cancer, 376 
in gynecologic operations, 

changes in, 365 
in normal pregnancy, 24 
in toxemia in pregnancy, 48 
increased, after gynecologic op- 
erations, 355 
Dietary, 391 

Dilatation of prepuce, 230 
Dilution of cows' milk, 190 
Discipline of operating-room, 339 
Diseases, gynecologic, 256 

mental, complicating pelvic dis- 
orders, 382 
of lungs in infants, 213 
of women, 256 
pulmonary, in infancy, 214 
specific, 386 
venereal, 386 
Disinfection, 406 
of birth-canal, 157 
of body of nurse, 406 
of cervix, 157, 158 
of field of operation in cases not 
requiring opening of per- 
itoneal cavity, 306 
of operator's body, 406 
of rectum, 162 

of vagina for operations on 
womb, 157 
for secondary operations, 157 
Disorders in infancy, 209, 221, 233 
constitutional, 234 
of gums in infancy, 211 
of mouth in infancy, 211 
Distention, abdominal, after gyne- 
cologic operations, 351 
Dorsal position, 164, 268 
Douche, intra-uterine, 155 
Douche-pans, 287 

zinc, 288 
Douches after la1)or, 73 

after plastic operations, 291 
dangers in use of, 290 
in gynecologic diseases, 282 
in operations on womb, 161 



INDEX. 



425 



Douches, intestinal, 292 

posture of patient in, 292 

solutions for, 292 

tubes for giving, 292 
method of giving, 28S 
posture of patients for, 287 
quantity of, 286 
syringes for, 286 
temperature of, 286 
vaginal, 282 

astringent, 283 

boric-acid, 285 

boroglycerid, 285 

carbolic-acid, 284 

creolin, 284 

hot, 282 

in first stage of labor, 68 

lysol, 285 

mercuric-chlorid, 283 

potassium-permanganate, 285 

salt-solution, 285 

thymol, 285 
vesical, 293 

apparatus for, 294, 296 

fluid employed in, 293 

method of giving, 295 

posture of patient for, 294 
while wearing pessary, 281 
Douche-tubes, 74, 286 
Douching, intra-uterine, in septic 

cases, 153 
Drainage during puerperal period, 

87 I 

in puerperal breast-abscess, 182 \ 
of abscesses in septic cases, 154 j 
Drainage-tube, care of, 357 ' 

glass, 357 _ ! 

Dressing-forceps, Davis's uterine, ^ 
132 I 

Dressing-room, doctor's, 319 j 

Dressings after operative treatment 
of cancer of breast, 375 
for confinement, 57, 62 
for operations on pelvic floor, 165 
on perineum, 165 
on vagina, 165 
on womb, 161 
for symphysiotomy, 137 
for use in gynecologic cases in 

private houses, 328 
for vaginal celiotomy, 370 
method of rendering antisepjic, 
59 



Dressings of absorbent cotton and 
cheesecloth, 58 
preparation of, 398, 416 
soiled, disposition of, 84, 414 
vulvar, changing of, 88 
material for, 57 
Dry-heat method of sterilization, 
396 

Earache in infancy, 225 
Eclampsia in pregnancy, iii 
Ectopic pregnancy, 13 
Eczema in infancy, 240 
Edebohls' speculum, 264 
Egg and lemon, 393 

and milk, 393 
Egg-nog, 393 

Electric apparatus for gynecologic 
examination, 265 
for operating-room, 324 

treatment of gynecologic diseases, 

. . 303 ' . . 
Electricity in pernicious nausea in 

pregnancy, 42 
Embryo, growth of, 13 
Embryotomy, 139 
Emergencies in gynecologic cases in 

private houses, 328 
Emergency feeding, 197 
Emmet's cervix needle, 131 
Enemata containing milk, 393 
Enlargement of breasts in infancy, 

239 
Eutopic pregnancy, 13 
Ec[uipoise waist, 26 
Eruptions in infants, 219 
Ether, examination under, 265 
Exercise for growing child, 254 

in normal pregnancy, 26 
Expulsive stage of labor, 53 
Extra-uterine pregnancy, 13 
Eye, foreign bodies in, in infancy, 

226 
P3yes, 221 

care of, in gynecologic patients, 

300 

Faintness in pregnancy, 35 
Fallopian tubes, anatomy of, 19 
Fecal impaction in pregnancy, 37 
Feeding and nursing of child, 189 

bottles for, 191 

by bowel in pernicious nausea, 44 



426 



INDEX. 



Feeding by inunction in pernicious 
nausea, 46 

emergency, 197 

forced, in insane, 298 

medicines with, 199 

of child, artificial, 199 
mixed, 199 
partial, 199 

prematurely-borne children, 206 

record of, 200 

rectal, in gynecologic patients, 
299 

with proprietary foods, 199 

without bottles, 200 
Feet-and-breech delivery, 78 
Fergusson's speculum, 264 
Fetal movements, 30 

skull, 16 
Fetus, 14 

effect of mother's condition on, 

23 

expulsion of, 20 

nutrition of, 19 

oxygen-supply of, 19 

position of, in womb, 15 
Fever in puerperal sepsis, 171 
Figure, 94 

Fissures in nipples, 180 
Flaxseed tea, 393 

Food after gynecologic operations, 
352' 

for first stage of labor, 68 

for gynecologic patients, 298 

for infant, 199 

for newborn child, 96 

preparation of, in pernicious nau- 
sea in pregnancy, 43 

proprietary, in child's bottle, 199 
Forced feeding in insane, 298 
Forceps, delivery by, 130 

dressing-, Davis's uterine, 132 

obstetric, Davis's, 131 

Pean's, 156 

sheet, 134 

shot, 165 

tenaculum, 132, 264 

volsella, 132 
Foreign bodies in the eye, 226 
in the nose, 226 
in the throat, 226 
Formaldehyd apparatus, 407 

as a sterilizing medium, 397 

fumigation by, 406 



Formaldehyd lamps, 407 

sterilizer, Reik's, 397 
Formulae for rectal feeding in per- 
nicious nausea, 45 
Fractures in infancy, 217 
French incubator, 203 
Fresh air in normal pregnancy, 

Fumigation, 406 

formaldehyd, 406 
Fiirbringer's method of sterilizing 

hands, 329 
Furniture for operating-room, 325 

Gauze, antiseptic, to prevent re- 
turn of postpartum hem- 
orrhage, 118 

bichlorid, 398, 414 

cheesecloth, 398 

cotton, 400 

iodoform, 399, 408, 413 

pads for abdominal operations, 
414 

sterile, for use in gynecologic ex- 
aminations, 261 
preparation of, 413 

strips for packing, 414 

washing and re-sterilization of, 

399 
Glass drainage-tube, 357 
Gloves in operations, 332 

preparation of, 418 

sterilization of, 406, 418 
Glycerin, sterilization of, 417 
Gonorrhea, 386 

care of nurse in, 388 

conveyance of, 387 

effects of, 386 

treatment of, 387 
Goodell's uterine dilator, 155 
Gowns, sterilization of, 401 
Green soap, 158 

tincture of, 158 
Growth of embryo, 13 

of ovum, 13 

of uterus in normal pregnancy, 
28 
Gruel, barley-, 391 

corn-, 393 

oatmeal-, 395 

rice-, 395 

wheat-, 395 
Gruels for child-feeding, 199 



INDEX. 



42; 



Gums, disorders of, in infancy, 211 

lancing of, 242 
Gymnastics, postural, for gyneco- 
logic pa-tients, 303 
Gynecologic diseases, causes of, 256 
douches in, 282 
treatment, electrical, 303 
local, 276 
examination, 259 
nursing, 256 
operations, 305 

abdominal distention after, 351 

dressing after, 361 
after-duties, 341 
anesthetizer in, 337 
apparatus for, 319, 336 
care during convalescence, 345 
of drainage-tube after, 357 
of rectum before, 335 
of skin after, 356 
change of posture after, 356 
convalescence from, 361 
diet in, 365 

final preparations for, 335 
first movement of bowel after, 

353 
food after, 352 
gloves in, 332 
hemorrhage after, 343 
immediate preparations for, 

329 
in private houses, 328 
increased diet after, 355 
not opening peritoneal cavity, 

305 
nurse in, 359 
opening peritoneal cavity, 311 

duties of nurse in, 315 
patient's room after, 341 
physician's clothing in, 337 
postures in, 268 
preliminary preparations for, 

333 
recovery from, 361 
re-dressing after, 362 
removal of stitches after, 363 
restlessness after, 350 
septic infection after, 346 
shock after, 343 
sitting up after, 365 
stimulants after, 352 
stitch-hole abscess after, 364- 
thirst after, 350 



Gynecologic operations, ventral 
hernia after, 366 
vomiting after, 342 
patients, 256 

Habits in bowel-movements in in- 
fancy, 211 

of child, 201 
Hands, preparation of,- 418 

sterilization of, 329 
Hank's cervix needle, 131 
Hare-lip, 231 

Height of child, gain in, 246 
Hemorrhage after laparotomy, 344 

after gynecologic operations, 343 

during labor, 114 

from infant's mouth, 212 

from umbilicus, 218 

in abortion, 108 

in circumcision, 229 

in pregnancy, 108 

in vaginal celiotomy, 370 

postpartum, 115 
tamponade in, 118 
transfusion in, 118 
Hereditary syphilis, 389 
Hernia in infants, 233 

ventral, after abdominal section, 
366 
Hodge pessary, 279 
Hominy jelly, 394 
Hot vaginal douche, 282 
House examination of gynecologic 

patients, 261 
Hydrocephalus, 235 
Hygiene of normal pregnancy, 26 
Hypodermoclysis in pernicious nau- 
sea in pregnancy, 42 
Hysterectomy for diseased womb, 
154 

Immediate repair of lacerations, 

149 
Impaction, fecal, in pregnancy, 37 
Improvised apparatus for opera- 
tions, 327 

operating-room, 326 
Incinerating soiled material, 414 
Incubation, 203 
Incubators, 203 

substitute for, 204 
Indigestion in infants, 201 
Induction of labor, 148 



428 



INDEX. 



Infancy, bowel-movements in, hab- 
its of, 211 

burns in, from hot-water bag, 217 

constipation in, 209 

convulsions in, 242 

cyanosis in, 233 

dentition in, 213 

diseases of lungs in, 213 

disorders of, 209, 221, 233 

earache in, 225 

eczema in, 240 

enlargement of breasts in, 239 

eruptions in, 219 

foreign bodies in eye in, 226 
in nose in, 226 
in throat in, 226 

fractures in, 217 

hernia in, 233 

injuries in, 216 

intestinal parasites in, 237 

intussusception in, 227 

itch insect in, 237 

jaundice in, 238 

malformations in, 228 

mouth in, bleeding from, 212 

pneumonia in, 213 

pulmonary diseases in, 214 

retention of urine in, 228 

salt rheum in, 240 

scalp-crusts in, 241 

scrofula in, 235 

septic infection in, 216 

sprue in, 211 

suppression of urine in, 239 

thrush in, 211 

tuberculosis in, 235 

vaccination in, 243 

wounds in, 216 
Infant, care of, 95 

parasites attacking, 236 

stools of, 200 
Infection in cancer cases, 380 

septic, after gynecologic opera- 
tions, 346 
in infants, 327 
Insanity, forced feeding in, 298 
Instrument-cases, 322 
Instruments and appliances for 
vaginal celiotomy, 370 

care of, 401 

for forceps delivery, 130 

for gynecologic examinations, 
260, 308 



Instruments for obstetric opera- 
tions, sterilization of, 129 
for operations on pelvic floor, 164 
on perineum, 164 
on vagina, 164 
on womb, 160 
for symphysiotomy, 137 
for transfusion, 323 
preparation of, 401, 416 
sterilization of, 416 
Intestinal discharges of newborn 
child, 95 
douches, 292 
massage in gynecology, 301 

with salines, in gynecology, 302 
parasites in infancy, 237 
Intestines of gynecologic patients, 

care of, 304 
Intra-uterine douching in septic 
cases, 153 
pregnancy, 13 
Intussusception in infancy, 227 
Inunction feeding in pernicious 

nausea, 46 
Involution, 80 

Iodoform gauze, preparation of, 
399, 408, 413 
sterilization, 417 
Irrigators, sterilization of, 417 
Irritability of bladder in pregnancy, 

Itch insect in infancy, 237 

Jars, antiseptic covers for, 332 

sterilization of, 417 
Jaundice in infancy, 238 

in newborn child, 96 
Jelly, barley-, 391 

hominy-, 393 

oatmeal-, 395 

rice-, 395 

wheat-, 395 
Junket, 394 

Keen's method of sterilizing hands, 

330 
Kelly pad, 133, 288 
Kelly's cervix needles, 131 
hvsterectomy needle, 156 
method for preparation of ma- 
rine sponges, 404 
Kidney, discharges from, in new- 
born child, 95 



INDEX. 



429 



Knee-chest posture, 35, 271 
Koeberle's serrenttud, 156 
Koumiss, 394 

Kronig's method for preparing cat- 
gut, 409 

Labor, 50 

accidents of, 114 

after-treatment of, 56 

binder in, 75 

diet after, 86 

douches after, 73 

duties of nurse during, 67 

first stage of, 52, 67 

hemorrhage during, 114 

induction of, 148 

lacerations in, 72 

pains after, 185 
during, 51 

preparations for, 56 

recognition of, 50, 52 

rupture of membranes in, 54 

twin, 79 

use of malt after, 87 

with breech presentation, 78 

without doctor, 75 
Lacerations, immediate repair of, 
149 

in labor, 72 

of vagina, secondary operations 
for, 162 

primary repair of, 149 

stitches closing, care of, 151 
removal of, 152 
Lancing of gums, 242 
Laxatives for infant constipation, 

210 
Leg, milk-, 184 

Leggings during operations, 60 
Leg-holder, improvised, 268 

Robb's, 134 
Legs, curvature of, 230 

puerperal thrombosis of, 184 

swelling of, in normal pregnancv, 
36 
Lemon and egg, 393 
Ligatures for confinement, 64 
Light for operations in private 
houses, 125 

in gynecologic examinations, 261, 
265 
Linen for operations, 320 

old, sterilization of, 61 



Linen, soiled, washing of, 81 

Lithotomy posture, 268 

Lochia, 80 

Lower extremities, puerperal 

thrombosis of, 184 
Lungs, diseases of, in infants, 213 
Lying-in period, 80 
Lysol douche, 285 

for disinfecting instruments, 266, 

402 

Malformations, 228 
Malt, use of, after labor, 87 
Mammary glands, 30 
Mania complicating pelvic disor- 
ders, 383 
Manicuring in gynecologic patients, 

300 
Marasmus, 236 
Marine sponges, preparation of, 

404-406, 416 
Massage, abdominal, for constipa- 
tion in infancy, 209 
in gynecologic patients, 301 
in puerperium, 83 
intestinal, with salines, in gyneco- 
logic patients, 302 
of newborn child, T03 
Meconium, persistence of, 240 
Melancholia complicating pelvic 
disorders, 382 
in puerperium, 187 
Membranes, expulsion of, 56 
rupture of, in labor, 53 
premature, no 
Menopause, effect of, on mental 

condition, 384 
Mental depression in gynecologic 
patients, 257 
diseases complicating pelvic dis- 
orders, 382 
Mercuric chlorid douche, 283 
Milk, abnormal, in puerperium, 
181 
cleanliness with, 190 
cows', care of, 193 
composition of, 193 
dilution of, 190 
excess of, in puerperium, 176 
lack of, in puerperium, 176 
mixing of, 194 
mother's. 07 
pancreatizing, 191 



430 



INDEX. 



Milk, Pasteurizing, 194 
peptonized, 393 
peptonizing, 191 
preparation of, for feeding, 191 
of twenty-four-hour quantity, 
196 
sterilizing, 194 
Milk-crusts, 241 
Milk-punch, 395 
Mixed feeding of child, 189 
Mixing milk, 194 
Monsters, 228 
Morning-sickness, 32 
Mother, body of, changes in, during 
pregnancy, 19 
cleanliness of, in puerperium, 82 
condition of, effect of, on child in 

utero, 23 
keeping of child near, 84 
time of getting up, 92 
^Mother's figure, 93 

milk, 97 
Motoring in pregnancy, 27 
Mouth, care of, in pregnancy, 301 
in infancy, bleeding from, 212 

disorders of, 211 
of newborn child, cleansing of, 
121 
Mutton-broth, 44, 392 

Nausea of pregnancy, ^2 
pernicious, in pregnancy, 40 
bed-sores in, 47 
bowel-feeding in, 44 
inunction-feeding in, 46 
rectal feeding in, 44-46 
treatment of, 41 
Needles for gynecologic operations, 
308' 
preparation of, 402 
Nerves of child, care of, 249 
Nervous system, effect of meno- 
pause, 384 
of child, development of, 247 
Newborn child, artificial breathing 
for, 121 
asphyxia of. 120 
bathing of, loi 
care of, 57, 95 
eyes of, 104 
mouth of, 104 
clothing of, 100 
development of bones in, 16 



Newborn child, first discharges 
from the bladder and 
bowels in, 105 
food for, 96 
giving breast to, 82 
habits of, 105 
intestinal discharges of, 95 
jaundice in, 96 
massage of, 103 
mouth of, cleansing of, 121 
nursing of, 98 
physiology of, 95 
sleep of, 100 
stomach of, 98 
syphilis in, treatment of, 389 
urine of, 95 
warmth for, 100 
washing of eyes of, 102 
water for, 99 
Nipples, abnormal, 179 
anatomy of, 32 
bottle, 192 
care of, during puerperium, 89 

in pregnancy, 32 
cracks in, 180 

development of, in pregnancy, 22 
dried secretions on, 31 
fissures in, 180 
• sunken, 179 

ulcers on, 181 
Nipple-shield, 180 
Normal salt solution, 416 
Nose, foreign bodies in, in infancy, 

226 
Nurse, care of, in gonorrheal cases, 
388 
clothing for, in operations, 338 
dangers to, in cancer cases, 381 
disinfection of body of, 406 
duties of, during labor, 67 

during operations on vagina, 
pelvic floor, and peri- 
neum, 166 
in forceps delivery, 134 
in gynecologic operations, 315, 

'359 
in postpartum hemorrhage, 

116 
in repair of lacerations, 150 
giving of anesthetic by, in ob- 
stetric operations, 127 
in puerperal sepsis, 174 
oflace, duties of, 265 



INDEX. 



431 



Nurse, training of, in operative 
work, 340 

Nursery refrigerators, 194 

Nursing, advantages of, 189 
and feeding of child, 189 
child in puerperal sepsis, 175 
gynecologic, 256 

in complications of pregnancy, 37 
in pernicious nausea, 41 
in puerperal sepsis, 169 
newborn child, 98 
obstetric, definition of, 11 
of normal pregnancy, 23 

Nutrition of fetus, 19 

Oatmeal-gruel, 395 
Oatmeal-jelly, 395 
Oatmeal-water, 395 
Obstetric forceps, Davis's, 131 

nursing, definition of, 11 

operations in septic cases, 153 

surgery, 123 
Office examination of gynecologic 
patients, 259 

nurse, duties of, 265 
Operating-rooms, 316 

basins for, 322 

discipline of, 339 

electrical apparatus for, 324 

furniture for, 325 

improvised, 327 

preparation of, for furniture, 326 

stands for, 322 

trays for, 322 

wash-stands for, 322 
Operating-table, 321 
Operations, anesthesia in, 126 

forceps, 130. See also Delivery 
by forceps. 

gynecologic, 305 

in private houses, clothing for, 

light for, T25 
preparations for, 1.23 
sterilizing utensils for, 124 
Trendelenburg posture in, 
123 
not opening peritoneal cavity, 

305 
obstetric, 123 

in septic cases, 153 
on womb, 157 
plastic douches after, 291 



Operations, sterilization of instru- 
ments for, 129 
Operative work, training of nurses 

in, 340 
Ophthalmia neonatorum, 221 
precautions in, 224 
treatment of, 222 
Ovum, growth of, 13 
Ox-gall preparation to soften fecal 

matter, 39 
Oxygen apparatus, 323 
Oxygen-supply of fetus, 19 
Osyter-broth, 392 

Packing, gauze strips for, 414 
Pad, Kelly, 133 

Pads for treating protruding um- 
bilicus, 218 
gauze for abdominal operations, 
414 
Pain in cancer, 379 
Pains, after-, 185 

of labor, 51 
Palate, cleft, 233 
Pancreatizing milk, 191 
Paquelin thermocautery, 324 
Parasites attacking infants, 236 

intestinal, in infancy, 237 
Partial feeding of child, 189 
Pasteurizing milk, 194 
Patients, gynecologic, examination 
of, 259 
electric light for, 265 
in private houses, 261 
office, 259 
postures in, 268 
under ether, 265 
food for, 298 
general care of, 297 
management of, 257 
massage for, 301 
peculiarities of, 257 
postural gymnastics for, 303 
rest for, 297 
posture of, in operations on 
womb, 159 
Patient's room after operation, 341 
Pean's hysterectomy forceps, 156 
Pedicle silk, 403 
Pedicuring in gynecologic patients, 

300 
Pelvic disorders, mental diseases 
complicating, 382 



432 



INDEX. 



Pelvic floor, secondary operations 
on, for laceration, 162 
massage for gynecologic patients, 

302 
organs, cancer of, 372 
Pelvis, abscesses in, drainage of, 
154 
bony, 20 
Peptonizing milk, igi, 394 
Perineum, secondary operations on, 
for lacerations, 162 
wounds of, nature's safeguards. 

Pernicious nausea in pregnancv, 40 
Perversions complicating pelvic dis- 
orders, 382 
Pessaries, 279 

for retroversion, 279 

introduction of, 280 

readjustment of, 281 

removal of, 281 
Pessary, Hodge, 279 

Smith, 279 

spiral, 279 

Thomas, 279 
Phimosis as cause of retention of 

urine in infants, 228 
Physiology of pregnancy, 16 
Placenta, 15, 16 

delivery of, 77, 78 

expulsion of, 56 
Plastic operations, douches after, 
291 

surgery, 157 
Pledget, 277 

Pneumonia in infancy, 213 
Positions. See Posture. 
Postpartum bleeding, 115 
Postural gvmnastics for gvnecologic 

patients, 194 
Posture, bending-forward, 275 

changes of, after gvnecologic 
operations, 356 

dorsal, 164, 268 

knee-chest, 7^^, 271 

lithotomy, 268 

of puerperal patient, 83 

Sims's, 160, 269 

squatting, 274 

standing, 274 

Trendelenburg, 271 
Pratt's uterine dilator, 155 
Pregnancy, 13 



Pregnancy, abnormal, 13 
accidents of, 106 
anatomy of, 19 
bleeding in, 108 

changes in body of mother in, 19 
complications of, nursing in, 37 
constipation in, 39 
convulsions in, in 
development of breasts during, 

22 
discharge from vagina in, 17 

of amniotic fluid in, no 
eclampsia in, in 
enlargement of veins in, 109 
extra-uterine, 13 
fecal impaction in, 37 
full-term, 16 
hemorrhage in, 108 
insanity in, 187 
intra-uterine, 13 
length of, 16 
medical care during, 21 
melancholia in, 187 
nausea of. 32 
normal, 13 

after-birth in, 18 

bathing in, 27 

breasts in, 30 

care of nipples in, 32 

clothing in, 24 

constipation in, 33 

descent of child in, 28 

diarrhea in, 34 

diet in, 24 

exercise in, 26 

faintness in, 35 

fetal movements in, 30 

fresh air in, 27 

growth of uterus in, 28 

increase in size of abdomen, 
28 

irritability of bladder in, t^2> 

morning-sickness in, 32 

motoring in, 27 

nursing of, 23 

position of child in uterus in, 

17 

quiet in, 27 

size of uterus in, 19 

swelling of legs in, 36 

syncope in, 35 

uterine contractions in, 29 

ventilation of room in, 27 



INDEX, 



433 



Pregnancy, pernicious nausea in, 
40 
physiology of, 16 
premature rupture of membranes 

in, no 
rupture of veins of leg in, log 
syncope in, 112 
toxemia of, 47 
Prepuce, dilatation of, 230 
Prolapse of umbilical cord, 119 
Pubiotomy, 137 
Puerperal insanity, 197 
sepsis, bed-sores in, 173 

cleansing birth-canal in, 170 
nourishment in, 172 
nursing child in, 175 
nursing in, 169 
operations for, 173 
prevention of, 169 
symptoms of, 169 
treatment of fever in, 171 
thrombosis of lower extremities, 
184 
Puerperium, 80 

asepsis during, 87^ 90 
bowels in, 80 
breast-abscess in, t8i 
breasts in, care of, 89 
caked breasts in, 177 
cleanliness of mother in, 82 
cleansing of vulva in, 88 
complications of, 176 
diet during, 86 
drainage during, 87 
duration of, 80 
insanity in, 187 
massage in, 83 
melancholia in, 187 
posture of patient in, 83 
rest in, 81 
visitors during, 91 
warmth during, 85 
Pulmonary diseases in infants, 214 
Pulse, 115, 147 

Recovery-room, 318 
Rectal feeding in gynecologic pa- 
tients, 299 
injections in pernicious nausea, 
feeding by, 44 
medication by, 46 
Rectum, care of, before gynecologic 
operations, 335 



Rectum, disinfection of, for sec- 
ondary operations on pel- 
vic floor, 162 
on perineum, 162 
on vagina, 162 
preparation of, for operations on 
womb, 159 
Refrigerator, nursery, 194 
Reik's formaldehyd sterilizer, 397 
Repair of lacerations, immediate, 

149 
Rest for gynecologic patients, 297 

in puerperium, 81 
Restlessness after gynecologic oper- 
ations, 350 
Retention of urine in infancy, 228 
Retroversion of uterus, pessaries 

for, 279 
Rice-gruel, 395 
Rice-jelly, 395 
Rice-water, 395 
Rickets, 234 
Ringworm, 237 
Robb's leg-holder, 134 
Room for confinement, 63 
Rubber gloves, sterilization of, 406 

sheeting, 59 
Rupture of membranes in labor, 53 

Saline fluid, intravenous transfu- 
sion of, for pernicious 
nausea, 42 
injections for constipation in 
pregnancy, 39 
Salt rheum, 240 

solution as vaginal douche, 285 
normal, preparation of, 416 
Sandwich, scraped-beef, 391 
Scalp-crusts in infancy, 241 
Schatz's method for hands, 329 
Schimmelbusch's sterilizer, 319 
Scrofula in infancy, 235 
Seat-worms in infants, 237 
Secretions, dried, on nipples, 31 
Sepsis, puerperal, 169 
Septic cases, drainage of abscesses 
in, 154 
intra-uterine douching in, 153 
operations in, 153 
infection after gynecologic oper- 
ations, 346 
in infants, 216 
Sheeting, rubber, 59 



434 



INDEX. 



Sheets, sterilization of, 401 

Shock after gynecologic operations, 

343' 

in vaginal celiotomy, 370 
Shot compressing forceps, 165 
Sickness, morning-, 32 
Silk, pedicle, 403 

preparation of, 403 

sterilized, preparation of, 416 
Silkworm-gut, preparation of, 416 

sterilization of, 403 
Sims' cervix needle, 131 

position, 160, 269 

speculum, 263 
Skene's cervix needle, 131 
Skin, care of, after gynecologic 
operations, 356 
in gynecologic patients, 300 

treatment of, before gynecologic 
operations opening perito- 
neal cavitv, 314 
Skull, fetal, 16 
Smith's pessary, 279 

wire ecraseur, 156 
"Sneakers" for nurses, 338 
Soap, green, 158 

tincture of, 158 
Soap-stick, 210 

Soiled dressings, disposition of, 84, 
414 _ 

linen, washing of, 81 
Specific disease, 386 
Specula, 263 
Speculum, bivalve, 263 

Edebohls', 264 

Fergusson's, 264 

Sims's, 263 
Spiral pessary, 279 
Sponges, marine, 404, 416 
Sprue, 211 

Squatting posture, 274 
Standing posture, 275 
Stands for operating-room, 322 
Steaming as means of sterihzation, 

396 
Sterilization, 396 

by boiling, 396 

by dry heat, 396 

by formaldehyd, 397 

by steaming, 396 

of blankets, 401 

of boric acid, 417 

of caps, 401 



Sterilization of cotton, 400 
of dressings, 416 
of gloves, 406, 418 
of glycerin, 417 
of gowns, 401 
of hands, 329 

Davis's method, 330 
Fiirbringer's method, 329 
Keen's method, 330 
Philadelphia Hospital method, 

418 
Schatz's method, 329 
of instruments for obstetric oper- 
ations, 129, 416 
of iodoform, 417 
of irrigators, 417 
of jars, 417 
of old linen, 61 
of sheets, 401 
of silkworm-gut, 403 
of surgeon's gowns, 418 
of sutures, 403 
of tables, 418 
of towels, 401 
SteriHzed silk, preparation of, 416 
Sterilizer, Arnold, 320 

Schimmelbusch's, 319 
Sterilizers, 319 

for gynecologic operations, 308 
formaldehyd, Reik's, 397 
Sterilizing milk, 194 

utensils in operations in private 
houses, 124 
Sterilizing-room, 318 
Stimulants in gynecologic opera 
tions, 308, 352 
in puerperal sepsis, 172 
Stimulation by mouth after gyneco- 
logic operations, 355 
for prematurely-born children 

206 
in asphyxia, 122 
Stitches closing lacerations, care of, 

removal of, 152 
removal of, after gynecologic 
operations, 363 
after operations on womb, 161 
Stitch-hole abscess, 364 
Stomach of newborn child, 98 

washing out of, 41 
Stools, infant's, 200 
Store-room, 318 



INDEX. 



435 



Strips, adhesive, preparation of, 401 
gauze, for packing, preparation 
of, 414 
Stupe, turpentine, for puerperal 

sepsis, 171 
Suppositories for constipation in 
infancy, 210 
of pregnancy, 40 
Suppression of urine in infancy, 239 
Surgeon's body, disinfection of, 406 
gowns, preparation of, 418 

sterilization of, 418 
operating suit, 338 
Surgery, obstetric, 122 
Surgical supplies, preparation of, 

396, 412 
Sutures for gynecologic operations, 
308 
for operations on pelvic floor, 
164 
on perineum, 164 
on vagina, 164 
on womb, 160 
sterilization of, 403 
Symphysiotomy, 137 
after-care, 138 
instruments for, 137 
Svncope in pregnancv, 35, 112 
Syphilis, 388 

conveyance of, 389 
results of, 389 
treatment of, 388 
Syphilitic cases, precautions of 
nurses in dealing with, 390 
Syringes for douches, 286 

Table, antiseptic covers for, 332 

Boldt's, 321 

for operations, 159, 163 

preparation of, 418 

sterilization of, 418 
Tamponade in post-partum bleed- 
ing, 118 
Tampons, 277 

carded-wool, 278 
Tea, beef-, 391 

flaxseed-, 393 
Teeth, care of, in gynecologic pa- 
tients, 301 

growth of, 213, 252 
Teething, care during, 254 
Tenaculum forceps, 132, 264 
Thermocautery, Paquelin, 324 



Thirst after gynecologic operations, 

350' 
of newborn, 96 
Thomas pessary, 279 
Thread-worms in infants, 237 
Throat, foreign bodies in, 226 
Thrombosis, puerperal, of lower 

extremities^ 184 
Thrush, 211 
Thymol douche, 285 
Toast- water, 395 
Tongue-tie, 234 
Towels, sterilization of, 401 
Toxemia of pregnancy, 47 
Training of nurses in operations, 

340 
Transfusion in treatment of post- 
partum bleeding, 118 
instruments for, 323 
Trays for operating-room, 322 
Trendelenburg posture, 271 

in operations in houses, 123 
Tuberculosis in infancy, 235 
Turning of child in womb, 136 
Turpentine stupe for puerperal sep- 
sis, 171 
Twin labor, 79 

Ulcers on nipples, 181 
Umbilical cord, 15, 16, 18 

appearance of stump of, 96 

care of, 56 

granulations about stump of, 

218 
prolapse of, 119 
Umbilicus, bleeding from 218 
dressing of, 103 
protruding, 218 
Urine of mother, 49 
of newborn child, 95 
retention of, in infancy, 228 
suppression of, in infancy, 239 
Uterine applicators, 276 
contractions, 29 
dressing-forceps, Davis's, 132 
Uterus. See Womh. 

Vaccination in infancy, 243 
Vagina, disinfection of, for opera- 
tions on womb, 157 
operations on, preparation for, 

secondary operations on, 162 



43^ 



INDEX, 



Vaginal capsules, 278 

celiotomy, 369 

discharge in pregnancy, 17 

douches, 282 

injections in first stage of labor, 
68 

irrigating nozzle, 283 

mucous membrane, scrubbing, 
158 
Veal-broth, 392 
Venereal disease, 386 
Ventilation in normal pregnancy, 
27 

of puerperal room, 84 
Ventral hernia after abdominal sec- 
tion, 366 
Version, 136 
Vesical douches, 293 
Visitors during puerperal period, 91 
Volsella forceps, 132 
Vomiting after Cesarean section, 

147 . 
after operation, 342 
pernicious, in pregnancy, 40 
Vulva, cleansing of, in puerperal 

period, 88 
Vulvar discharges, 230 
dressings, changing of, 88 
material for, 57 

Waist, equipoise, 26 
Walcher's position in forceps de- 
livery, 135 
Warmth for newborn child, 100 

in puerperium, 85 
Washing of gauze and bandages, 

399 
out of stomach, 41 
Wash-stands for operating-room, 

322 
Water for gynecologic patients, 299 



Water for newborn child, 99 

on the brain, 235 
Waters, bursting of, 53 
Weaning, 192 
Weight of child, 245 
Weir's method for sterilizing hands, 

419 
Wheat-gruel, 395 
Wheat-jelly, 395 
Wheat water, 395 
White-of-egg water, 391 
Womb, abnormal condition of, as 
cause of pernicious nau- 
sea, 47 
anatomy of, 19 
bleeding within, 108 
diseased, hysterectomy for, 154 
growth of, in normal pregnancv, 

28 
lining membrane of, shedding of, 

80 
operations on, 157 
appliances for, 159 
catheterizing in, 159 
disinfection of birth-canal for, 

157 
of cervix for, 157, 158 
of vagina for, 157 
douches in, 161 
dressings for, 161 
instruments for, 160 
posture of patient for, 159 
preparation of patient for, 157 

of rectum for, 159 
removal of stitches after, 161 
sutures in, 160 
table for, 159 
position of fetus in, 15 
retroversion of, pessaries for, 279 
Women, diseases of, 256 
Wounds of infants, 216 



SAUNDERS' BOOKS 

for 

NURSES 



Every Book Kept Up To Date By Frequent Revisions 

PAGE 

Aikens' Training School Methods and the Head Nurse . . 3 

Beck's Reference Handbook for Nurses 4,. 

Davis' Obstetric and Gj'necologic Nursing 5 

DeLee's Obstetrics for Nurses 5 

Borland's American Illustrated Dictionary 8 

Borland's American Pocket Medical Dictionary 6 

Fowler's Operating Room and Patient 4 

Friedenwald and Ruhrah on Diet 6 

Grafstrom's Mechanotherapy (Massage) 6 

Griffith's Care of the Baby 7 

Lewis' Anatomy and Physiology for Nurses 3 

McCombs' Diseases of Children for Nurses 7 

Morris' Essentials of Materia Medica 7 

Morrow's Immediate Care of the Injured 8 

Nancrede's Essentials of Anatomy . . • 4 

Paul's Materia Medica for Nurses 4 

Paul's Nursing in the Acute Infectious Fevers 5 

Pyle's Personal Hygiene , 8 

Register's Fever Nursing 8 

Stoney's Bacteriology and Surgical Technic 2 

Stoney's Materia Medica for Nurses 2 

Stoney's Nursing 2 

Wilson's Reference Handbook of Obstetric Nursing ... 7 



W. B. SAUNDERS COMPANY 

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chapter is the one on observation of symptoms which is very 
thorough. ' ' There are directions how to improvise everything 
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Practical Points in Nursing. By Emily M. A. Stoney, Superin- 
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RECENTLY ISSUED 
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Stoney's Materia Medica 

Stoney' s Materia Medica was written by a head nurse who 
knows just what the nurse needs. American Medicine says 
it contains * * all the information in regards to drugs that a 
nurse should possess. >i< >f^ * The treatment of poisoning 
is stated in a manner that will permit of its being carried out 
thoroughly and intelligently. ' ' 

Materia Medica for Nurses. By Emily M. A. Stoney, Superin- 
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South Boston, Mass. i2mo volume of 300 pages. Cloth, $1.50 net. 

Stoney's Surgical Technic rH^^'^.TskfT'^^S 

The first part of the book is devoted to Bacteriology and 
Antiseptics; the second part to Surgical Technic, Signs of 
Death, Autopsies, Bandaging and Dressings, Obstetric Nurs- 
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the Nurse, etc. The New York Medical Record says it " is a 
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Bacteriology and Surgical Technic for Nurses, By Emily M. A, 

Stoney. Revised by Frederic R. Griffith, M. D., New York. 

' i2mo volume of 278 pages, fully illustrated. Cloth, $1.50 net. 



Lewis' Anatomy and Physiology 

RECENTLY ISSUED 

This book is the outcome of a wide demand for such a work — 
one that would treat anatomy and physiology from the 7iurse's 
pobit of view. Dr. Lewis has based the plan and scope of his 
work on the methods employed by him in teaching these 
subjects to nurses. The Nurses Joicrfial of the Pacific .Coast 
says "it is not in any sense rudimentary, but comprehensive 
in its treatment of the subjects in hand." The application of 
the kno\^ledge of anatomy and physiology in the care of the 
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Anatomy and Physiology for Nurses. By LeRoy Lewis, M. D., Lec- 
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City,. Mich. i2mo of 317 pages, 146 illustrations. Cloth, $1.75 net. 

Aikens' Training-School Methods and 
the Head Nurse just issued 

This new work discusses those problems of the training 
school which constantly arise and to meet which the head 
nurse, unless she has had long experience in training-school 
management, is frequently at a loss. The plans suggested 
have been tested personally during many years' experience as 
director of hospital training schools, and the author's con- 
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on Hospital Ethics and Discipline will be found particularly 
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training school methods and the duties of the head nurse. 

Hospital Training-School Methods and the Head Nurse. By Char- 
lotte A. Aikens, late Director of Sibley Memorial Hospital, Wash- 
ington, D. C. lamo of 267 pages. Cloth, $1.50 net. 



Fowler's Operating Room NEw^d^DmoS 

Dr. Fowler's work contains all information of a surgical 
nature that a nurse must know in order to attain the highest 
efficiency. Canadian Journal of Medicine and Surgery says : 
"We find compactly and clearly stated just those thousand 
and one things which when required are so hard to locate." 

The Operating Room and the Patient. By Russell S. Fowler, 
M. D. , Professor of Surgery, Brooklyn Postgraduate Medical School. 
Octavo of 284 pages, with original illust tions. Cloth, $2.00 net. 



Nancrede's Anatomy 



NEW (7th) EDITION 

The A77ierican Journal of Medical Sciences says this work * ' is 
one of the best of all the question compends and will no doubt 
continue to enjoy its deserved success." 

Essentials of Anatomy. Charles B. G. deNancrede. M. D., Pro- 
fessor of Surgery and Clinical Surgery in the University of Michi- 
gan, Ann Arbor. i2mo, 400 pages, 180 illustrations. Cloth, $1.00 net. 

Beck's Reference Handbook recently issued 

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Montreal Medical Journal says it is "cleverly systematized and 
shows close observation of the sickroom and hospital regime." 

A Reference Handbook for Nurses. By AMANDA K. Beck, Grad- 
uate of the Illinois Training School for Nurses, Chicago, 111, 
32mo volume of 177 pages. Bound in flexible leather, $1.25 net 

Paul's Materia Medica for Nurses 

RECENTLY ISSUED 

Dr. Paul arranges the drugs alphabetically. The physiologic 
actions he arranges according to the actio7i of the drug and not 
the organ acted upon; thus, the full action of the drug may be 
seen at a glance. An important section is that on Pretoxic Signs. 

A Text-Book of Materia Medica for Nurses. By George P. Paul, 
M. D., Assistant Visiting Physician and Adjunct Radiographer to the 
Samaritan Hospital, Troy, N. Y. i2mo of 240 pages. Cloth, $1.50 net. 



DeLee's Obstetrics for Nurses 

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Dr. DeLee treats obstetrics from the nurse's point of view. 
The book really considers two subjects — obstetrics for nurses 
and the actual obstetric nursing. Trai7ied Nurse and Hos- 
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tions, and they are given with such clearness that they can- 
not fail to leave their impress upon the mind of the reader." 
The practical illustrations are nearly all original, having been 
made specially for this work. 

Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of 
Obstetrics at the Nortiiwestern University Medical School, Chi- 
cag-o. i2mo volume of 460 pages, fully illustrated. Cloth, $2.50 net. 

Davis' Obstetric & Gynecologic Nursing 

RECENTLY ISSUED— NEW (2d) EDITION 

Obstetric nursing demands some knowledge of natural preg- 
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occur during pregnancy and labor. The Trained Nurse and 
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Obstetric and Gynecologic Nursing. By Edward P. Davis, M. D., 
Professor of Obstetrics in the Jefferson Medical College, Philadel- 
phia. i2mo volume of 402 pages, illustrated. Buckram, $1.75 net. 

Paul's Fever Nursing recently issued 

Dr. Paul has laid great stress upon the care and management 
of each disease, as this relates directly to the duties of the 
nurse. The Londo7i Lancet thinks ' ' the book is an excellent 
one and will be of value to those for whom it is intended. 
The text is clear and full, and the illustrations are good." 

Nursing in the Acute Infectious Fevers. By George P. Paul, 
M. D., Assistant Visiting Physician and Adjunct Radiographer to 
the Samaritan Hospital, Troy, izmo of 200 pages. Cloth, $1.00 net. 



Friedenwald and Ruhrah's Dietetics 

lOr i 1 UrSeS recently issued 

This work has been prepared to meet the needs of the nurse, 
both in the training school and after graduation. It aims to 
give the essentials of dietetics, considering briefly the physi- 
ology of digestion and the various classes of foods. American 
Journal of Nursing says it "is exactly the book for which 
nurses and others have long and vainly sought. A simple 
manual of dietetics, which does not turn into a cook-book at 
the end of the first or second chapter. ' ' 

Dietetics for Nurses. By JuLius FRIEDENWALD, M. D., Clinical Pro- 
fessor of Diseases of the Stomach, and John Ruhrah, M. D., Clinical 
Professor of Diseases of Children, College of Physicians and Sur- 
geons, Baltimore. i2mo volume of 365 pages. Cloth, $1.50 net. 

American Pocket Dictionary "Iw rsyh'^omoN 

This is the ideal pocket lexicon. It contains a complete vo- 
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Trained Nurse and Hospital Review says : ' ' We have had 
many occasions to refer to this dictionary, and in every in- 
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also contains a wealth of anatomic tables of value to nurses, 

Dorland's Pocket Medical Dictionary. Edited by W. A. Newman 
DORLAND, M. D., of the University of Pennsylvania. riexible 
leather, with gold edges, $1.00 net; with patent thumb index, $1.25 net. 

Grafstrom's Mechano-therapy (2d) edit'Ion 

The Boston Medical and Surgical Journal says : * ' It states in 
concise language the various methods which by long experience 
have been found useful in treament by mechanical means." 

Mechano-Therapy (Massage and Medical Gymnastics). By Axel V. 
Grafstrom, B. Sc, M. D., Attending Physician, Gustavus Adolphus 
Orphanage, Jamestown, N. Y. i2mo, 200 pages. Cloth, $1.25 net. 

Friedenwald & Ruhrah on Diet ^DmSS 

Diet in Health and Disease, By Juwus Friede;nwai.d, 
M. D., CHnical Professor of Diseases of the Stomach, and 
John Ruhrah, M. D., CHnical Professor of Diseases 
of Children, College of Physicians and Surgeons, Balti- 
more. Octavo volume of 728 pages. Cloth, |4.00 net. 



McCombs' Diseases of Children for Nurses 

JUST ISSUED 

Dr. McCombs' experience in lecturing to nurses has enabled 
him to ^m^hdisiz^jicst those points that nurses most need to know. 
He has given a short but clear description of each disease found 
in infancy and childhood. Considerable attention has been 
accorded infant feeding and emergency measures. 

Diseases of Children for Nurses. By ROBERT S. McCOMBS, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2ino 
of 431 pages, illustrated. Cloth, $2.00 net. 

Wilson's Obstetric Nursing just ready 

In Dr. Wilson's work the entire subject is covered from the 
beginning of pregnancy, its course, signs, on to the approach 
of labor, its actual accomplishment, the puerperium and care 
of the infant, ahvays emphasizing the nurse' s duties. The book 
is bound in flexible leather, uniform with Beck's Handbook. 

A Reference Handbook of Obstetric Nursing. By W. Reynolds 
Wilson, M.D., Visiting Physician to the Philadelphia Lying-in Char- 
ily. 32mo of 355 pages, illustrated. Flexible leather, $1.25 net 

Morris' Materia Medica new (7th) edition 

The T^^ained Nurse and Hospital Review says: "The work is 
thoroughly up to date, well arranged, compact, and yet con- 
tains a very large amount of matter." 

Essentials of Materia Medica, Therapeutics, and Prescription Writing. 
By Henry Morris, M. D. Revis2d by W. A. Bastedo, M. D., 
Instructor in Materia Medica and Pharmacology at the Colum- 
bia University, New York. i2mo of 300 pages. Cloth; $1.00 net. 



RECENTLY ISSUED 
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Griffith's Care of the Baby 

The New York Medical Joiornal says: "We are confident if 
this little work could find its way into the hands of every 
trained nurse, infant mortality would be lessened by at least 
fifty per cent." 

The Care of the Baby. By J. P. Crozer Griffith, M. D., Clinical 
Professor of Diseases of Children, University of Pennsylvania. 
i2mo of 455 pages, illustrated, including 5 plates. Cloth, $1.50 net. 



Register's Fever Nursing just issued 

The work completely covers the field of practical fever nurs- 
ing. Just sufl&cient of pathology, symptomatology, and 
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lines has especially fitted him to write a thoroughly practical 
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text is well illustrated. 

A Text-Book on Practical Fever Nursing. By EDWARD C. REGISTER, 
M. D., Professor of the Practice of Medicine in the North Carolina 
Medical College. Octavo of 350 pages, illustrated. Cloth, $2.50 net 

Dorland's Illustrated Dictionary 

RECENTLY ISSUED— NEW (4th) EDITION— 2000 NEW TERMS 

This edition contains over 2000 new terms. Dr. Howard A. 
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been found in my use of it." 

The American Illustrated Medical Dictionary. A Dictionary of the 
terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, 
and kindred branches; with loo new and elaborate tables. By W. 
A. N. DORLAND, M. D. Large octavo of 836 pages, 293 illustrations, 
iiq in colors. Flexible leather, $4.50 net: thumb index, $5.00 net 

Morrow's Immediate Care of Injured 

RECENTLY ISSUED 

The Trained Nurse and Hospital Review says : * ' We are most 
pleased with the work. The illustrations are clear and prac- 
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Immediate Care of the Injured. By Albert S. Morrow, M. D., 
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A Manual of Personal Hygiene. Proper Living upon 
a Physiologic Basis. Edited by Wai^ter Iv. Pyi^e, A. 
M., M. D., Assistant Surgeon to Wills Eye Hospital, 
Philadelphia. Octavo, 451 pages, illustrated. $1.50 net. 



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